Cal. Code Regs. Tit. 22, § 51455 - Prior Authorization

(a) Any provider may be subjected to a requirement of prior authorization for all or certain specified services to be rendered under the California Medical Assistance Program, by written notice served on such provider from the Director or a carrier. The requirement for prior authorization may be imposed on such provider by the Director upon a determination that the provider has been rendering unnecessary services to a Medi-Cal beneficiary.

(b) As used in this regulation, "unnecessary services" includes but is not limited to any of the following which exceed customary and usual practices in terms of frequency, quantity, propriety, or length of treatment:

(1) Office, home or inpatient visits.

(2) Furnishing, prescribing or ordering drugs, appliances, services, hospital, skilled nursing facility or intermediate care facility admissions.

(c) The written notice of requirement for prior authorization shall state the nature, type, and extent of the services determined by the director to have been unnecessary, and shall also state which services shall be subject to prior authorization and the duration that such prior authorization shall remain in force.

Notes

Cal. Code Regs. Tit. 22, § 51455

1. Amendment of subsection (b) filed 8-8-78; effective thirtieth day thereafter (Register 78, No. 32). For prior history, see Register 70, No. 9.
2. Amendment of subsection (a) filed 8-16-78 as an emergency; designated effective 8-16-78 (Register 78, No. 32).
3. Certificate of Compliance filed 12-12-78 (Register 78, No. 50).
4. New NOTE filed 12-14-84 (Register 84, No. 50).

Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 14103.6 and 14133, Welfare and Institutions Code.

1. Amendment of subsection (b) filed 8-8-78; effective thirtieth day thereafter (Register 78, No. 32). For prior history, see Register 70, No. 9.
2. Amendment of subsection (a) filed 8-16-78 as an emergency; designated effective 8-16-78 (Register 78, No. 32).
3. Certificate of Compliance filed 12-12-78 (Register 78, No. 50).
4. New NOTE filed 12-14-84 (Register 84, No. 50).