Prior Authorization
Please note, failure to obtain authorization may result in administrative claim denials. Coordinated Care providers are contractually prohibited from holding any member financially liable for any service administratively denied by Coordinated Care for the failure of the provider to obtain timely authorization.
Check to see if a pre-authorization is necessary by using our online tool.
Expand the links below to find out more information.
As the Medical Home, PCPs should coordinate all healthcare services for Coordinated Care members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.
Some services require prior authorization from Coordinated Care in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.
Coordinated Care follows the authorization determination and requirements of HCA for professional services including dental services. Provide a copy of HCA’s approval letter, prior authorization number or EPA when you submit the facility claim.
Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.
Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.
Coordinated Care’s Medical Management department hours of operation are 8 a. m. a 5 p. m. Hora del Pacífico, lunes a viernes (excluding holidays). After normal business hours, Nurse Advice Line staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.
We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.
Medicaid MCOs are responsible for coverage of skilled nursing facility stays that meet rehabilitative or skilled level of care for Medicaid only individuals. Please follow this process for making requests for Medicaid only individuals.
Use this Process for Skilled Nursing Facility Requests (PDF) for contact information and clarification of process to assist with timely decisions regarding transitions to Skilled Nursing Facilities and ongoing authorization requests.