Authorization and Referral Timelines

According to the utilization management (UM) standards, all participating physician groups (PPGs) are required to:

• Approve or deny and process all routine authorization requests within the applicable regulatory time frame of the date of receipt of all information necessary to render a decision.
• If additional clinical information is required, the member and practitioner must be notified in writing within the applicable regulatory time frame of the extension.
• Communicate the decision to the member and practitioner within the applicable regulatory timeframe from the date of the original receipt of the request.
• Approve or deny and process all urgent requests for authorization within 72 hours after the receipt of the request for service.

The regulatory time frames begin when the delegated PPG's UM department receives a request for prior authorization. If the PPG's UM department receives a request for prior authorization of services and it is determined to be the plan's responsibility, the PPG must immediately forward the request to the plan as the regulatory time frames begin at the time of the original request. The Medicare Advantage Informational Letter to Member or Provider/Physician carve-out letter (PDF) serves to advise the member that the PPG's utilization management entity received a prior authorization request for which the PPG is not delegated to conduct a prior authorization review and notifies the member that the request has been forwarded to the plan (no Medi-Cal carve-out letter is available at this time). PPGs use the Medicare Advantage Information Letter for Cal MediConnect members. The regulatory time frame for the prior authorization review does not reset or stop when this letter is issued.

For additional information, refer to:

• Utilization Management Timeliness Standards - Medi-Cal (PDF)
• Utilization Management Timeliness Standards - Medicare (PDF)

For Cal MediConnect members, both Medicare and Medi-Cal timeliness standards apply. Medi-Cal timeliness standards apply for Medi-Cal covered services.