23-367sum Summary Update: Know What Changes are Coming for Prior Authorizations
Date: 04/26/23
Drugs that require prior authorizations now and more changes that start July 1, 2023
The complete update to the prior authorization (PA) changes is found on 23-367, Know What Changes are Coming for Prior Authorizations (PDF).
Key Changes | |
|---|---|
Requirement | Comments |
Incontinence supplies | Members under age 21 – the Plan will discontinue reviewing requests from participating providers for incontinence supplies effective July 1, 2023. - California Children’s Services (CCS) eligible diagnosis should be confirmed and related services directed to CCS. - For more information about the CCS member verification process go to the Department of Health Care Services (DHCS) Medical Authorizations and Claims. - We continue to follow Medi-Cal requirements regarding quantity limits. For additional information refer to the Quantity Limits outlined in the List of Incontinence Medical Supply Billing Codes (incont billing). |
Outpatient pharmaceuticals (medical benefit medications) | - New outpatient pharmaceuticals (medical benefit medications) requiring authorization per the new HCPCS issued by the Centers for Medicare and Medicaid Services (CMS) effective January 1, 2023 and April 1, 2023. - Additions, changes and deletions, effective July 1, 2023, to outpatient pharmaceuticals. |
Sleep studies | Home-based sleep testing no longer requires PA effective July 1, 2023. (Facility sleep testing continues to require PA.) |
Use the new Coram contact information
Coram is the Plan’s preferred infusion provider. Effective immediately, Coram can be contacted at the following numbers:
- Phone: 866-899-1661
- Fax: 866-843-3221
Additional information
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.