Manual Cal MediConnect Medi-Cal ... Medications Refer to the 2021 Medical Benefit Drug Prior Authorization Grid Physician administered drugs in the doctor’s office or in an outpatient setting Non-Contracted Providers All non-urgent/non-emergent services provided by non-contracted
Effective Date: 01/01/2021. Revised Date: 09/05/2020. This Prior ... apply. Refer to CMS,. Noridian, and/or. Medi-Cal Provider. Manual. Cal MediConnect. Medi- ...
manual wheelchairs except standard adult and pediatric, and motorized wheelchairs and accessories Respiratory: Oxygen, BIPAP, CPAP, ventilators Prosthetics & customized orthotics except off-the-shelf covered items Hearing aids and repairs Other specialty devices Requests over the benefit limit Experimental Procedure
Medical Covered Services Prior Authorization Grid This Prior Authorization Grid contains services that require prior authorization only and is not intended to be a comprehensive list of covered services. Providers should refer to the appropriate Evidence of Coverage (EOC) for a complete list of covered services. Santa Clara Family Health Plan (SCFHP) Utilization Management Department: Telephone: 1-408-874-1821 Prior Authorization Request Submission Fax Lines: 1-408-874-1957 When faxing a request to SCFHP, please: 1. Use the SCFHP Prior Authorization Request Medical Services Form found at www.scfhp.com 2. Attach pertinent medical records, treatment plans, test results and evidence of conservative treatment to support medical necessity. Other Contact Information: SCFHP Automated Eligibility: SCFHP Customer Service: Medi-Cal: Cal MediConnect: 1-800-720-3455 1-800-260-2055 1-877-723-4795 For Non-Emergency Medical Transportation (NEMT) & Non-Medical Transportation (NMT) contact SCFHP Customer Service Benefits Authorized by Vendors: Dental Services Denti-Cal: Vision Services Vision Service Plan (VSP): 1-800-322-6384 1-844-613-4779 1 40515 Medical Prior Authorization Grid Effective Date: 01/01/2021 Revised Date: 09/05/2020 Medical Covered Services Prior Authorization Grid Category of Service Behavioral Health Treatment Durable Medical Equipment (DME) *Benefit and frequency limits apply. Refer to CMS, Noridian, and/or Medi-Cal Provider Manual Experimental Procedure Home Health Inpatient Admissions Long-Term Services and Supports (LTSS) Services Requiring Prior Authorization All Behavioral Health Treatment Services for members age 21 years and under with behavioral conditions that may or may not include autism spectrum Cal MediConnect Medi-Cal Custom made items Any other DME or medical supply exceeding $1000 Prosthetics & customized orthotics exceeding $1000 Hearing aids and repairs Other specialty devices Requests over the benefit limit CPAP and BIPAP Enteral formula and supplies Hospital bed and mattress Power wheelchairs, scooters, manual wheelchairs except standard adult and pediatric, and motorized wheelchairs and accessories Respiratory: Oxygen, BIPAP, CPAP, ventilators Prosthetics & customized orthotics except off-the-shelf covered items Hearing aids and repairs Other specialty devices Requests over the benefit limit Experimental procedures Investigational procedures New technologies All home health services Home IV infusion services All elective medical and surgical inpatient admissions to: · Acute hospital · Long Term Acute Care (LTAC) All admissions for: · Acute inpatient psychiatric · Partial hospital psychiatric treatment · Substance use disorder including detoxification Rehabilitation and therapy services: · Acute rehabilitation facilities · Skilled Nursing Facilities (SNF) Community-Based Adult Services (CBAS) Long-Term Care (LTC) 2 40515 Medical Prior Authorization Grid Effective Date: 01/01/2021 Revised Date: 09/05/2020 Medical Covered Services Prior Authorization Grid Category of Service Medications Non-Contracted Providers Organ Transplant Outpatient Services and Procedures Services Requiring Prior Authorization Refer to the 2021 Medical Benefit Drug Prior Authorization Grid Physician administered drugs in the doctor's office or in an outpatient setting All non-urgent/non-emergent services provided by non-contracted providers All organ transplants Abdominoplasty/Panniculectomy Bariatric surgery Breast reduction and augmentation surgery Cataract surgery Cochlear auditory implant Dental surgery, jaw surgery and orthognathic procedures Dermatology: · Laser treatment · Skin injections · Implants All types of endoscopy except colonoscopy Gender reassignment surgery Genetic testing and counseling Hyperbaric oxygen therapy Intensive Outpatient Palliative Care (IOPC) Neuro and spinal cord stimulators Outpatient diagnostic imaging: · Magnetic Resonance Imaging (MRI) · Magnetic Resonance Angiography (MRA) · Nuclear cardiology procedures · Single-Photon Emission Computerized Tomography (SPECT) · Positron-Emission Tomography (PET/PET-CT) Outpatient therapies · Occupational Therapy (OT) · Physical Therapy (PT) · Speech Therapy (ST) All plastic surgery and reconstructive procedures Podiatric surgeries Radiation therapy: · Proton beam therapy · Stereotactic Radiation Treatment (SBRT) Sleep studies Spinal procedures except epidural injections Surgery for Obstructive Sleep Apnea (OSA) Temporomandibular Disorder (TMJ) treatment 3 40515 Medical Prior Authorization Grid Effective Date: 01/01/2021 Revised Date: 09/05/2020 Medical Covered Services Prior Authorization Grid Category of Service Transportation Services Requiring Prior Authorization Transplant-related services prior to surgery except cornea transplant Unclassified procedures Varicose vein treatment Non-Emergency Medical Transportation (NEMT) except ground transportation from facility to facility and hospital to home. 4 40515 Medical Prior Authorization Grid Effective Date: 01/01/2021 Revised Date: 09/05/2020Microsoft Word 2013 Microsoft Word 2013