Obtaining Prior Authorization

To access certain services you’ll need to get authorization first.

Except for Primary Care Physician (PCP) services, emergency services and obstetric and gynecologic services, you’re responsible for obtaining valid authorization before you receive covered HMO benefits.

To Obtain a Valid Authorization:
  • Prior to receiving care contact your PCP.
  • Request prior authorization for those covered benefits. In most cases, authorization requests for medical services will be reviewed by your utilization management team.
  • If authorization is approved you’ll be notified of the approved provider and the expiration date for the authorization.
  • If authorization is denied you’ll be informed of the reason for denial and your appeal rights.

How Community Care Health Plan Makes Decision about Your Care
Community Care Health Plan uses evidence-based guidelines for authorization, modification or denial of health care services. Plan-specific guidelines are developed and reviewed on an ongoing basis by Community Care Health Plan’s chief medical officer, the utilization management committee, and appropriate physicians who assist in identifying community standards of care. A copy of the guidelines used in the authorization process is available upon request.

At Community Care Health Plan, we make utilization management decisions based on appropriateness of care and service after confirming health coverage. The doctors and nurses who conduct utilization reviews are not rewarded for denials of care or service, and there are no incentives for utilization management decision-makers that encourage decisions resulting in underutilization of health care services.

Independent Medical Review
You may also be eligible for an independent medical review (IMR). If you’re eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.

The California Department of Managed Health Care has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's website www.hmohelp.ca.gov, has complaint forms, IMR application forms and further instructions.