Prior Authorization

The California Department of Corrections and Rehabilitation (CDCR) or the Department of Juvenile Justice (DJJ)* must provide written prior authorization for medically necessary services before a CDCR patient or DJJ* youth receives services. The prior authorization must be included in the CDCR patient or DJJ* youth’s treatment package provided at the time of treatment.

Medically necessary services are supported by outcomes data as effective medical care, and in accordance with Title 15 CCR, Division 3, Chapter 2, Article 1, § 3999.98. “Medically Necessary" means health care services that are determined by the attending or primary medical, mental health, or dental care provider(s) to be needed to protect life, prevent significant illness or disability, or alleviate severe pain, and are supported by health outcome data or clinical evidence as being an effective health care service for the purpose intended or, in the absence of available health outcome data, is judged to be necessary, and is supported by diagnostic information or specialty consultation.

On the day of the scheduled appointment, patients arrive with a treatment package. The treatment package is in the possession of the escorting correctional officer and contains the Health Care Services Physician Request for Services form. Participating providers must provide only those services listed on the form. They may not order additional tests, specialty services or make direct referrals.

If the participating provider believes additional medically necessary services are required, he or she must obtain written authorization from the headquarter (HQ) UM Regional Physician Advisor or Nursing Consultant Program Review (NCPR UM) case manager before performing any further non-emergency services. In these instances, an email address will be sent to the provider with instructions on the process. The written authorization for treatment will be communicated via CCHCS HQ UM Regional Physician Advisor by email within 24 hours of the request. These services include, but are not limited to:

• Non-emergency specialty treatment.
• Consultations by specialty physicians.
• Diagnostic procedures not specifically stated in the CCHCS Request for Services form.
• Any excluded services specifically listed in California Code of Regulation (CCR), Title 15, Division 3, Chapter 1, Subchapter 4, Article 8, Section 3350.1.

Providers send evaluations and recommendations back to the CDCR institution in the treatment package. The primary care provider for the institution reviews the evaluation and recommendations and authorizes additional services, as appropriate. Participating providers must not discuss the course of treatment or requests for additional services with the patient.

Participating providers are not reimbursed for services that are performed without prior authorization from CCHCS.

Participating hospitals must not transfer CDCR patients or DJJ* youth to other facilities without prior written authorization from the CDCR institution’s CEO, CME, or DJJ* FCMO or their designee unless there is a documented and verified need for emergency services that cannot be performed at the current facility.

Notification about emergent care

Hospital emergency rooms do not need to seek authorization prior to performing emergency evaluation and stabilization of the patient. Providers must notify CCHCS HQ UM Regional Physician Advisor via their email address to request approval authorization for additional treatment or services.

Notification to providers about changes

If CDCR/CCHCS adopts another objective standard for UM review to screen CDCR patients¹ regarding prior authorization, inpatient admissions, and other types of UM review, the Deputy Medical Executive (DME) for UM must notify the provider or other parties of the new standards no less than 30 calendar days before the new standard is implemented.

¹CDCR patient includes DJJ youth.

*As of June 30, 2023, all Divisions of Juvenile Justice (DJJ) are closed. Juvenile offenders are no longer committed to the DJJ as of this date. Effective July 1, 2023, claims for health care services rendered to the DJJ youth should be directed to the county where the patient is located. Claims for services rendered on or prior to June 30, 2023, will continue to be the responsibility of California Department of Corrections and Rehabilitation (CDCR).