Treatment & Referral Authorization Requirements
Treatment Authorization Policy
In order to provide better coordination and continuity of care to NEMS Managed Care members, specialist providers are required to obtain Treatment Authorizations prior to the performance of certain procedures and/or services. Services rendered without Prior Authorization from the NEMS Utilization Management Department are subject for Administrative Denial for reimbursement.
Usage of Treatment Authorization Request (TAR) forms applies to primary care providers (PCP), specialist providers, and other service providers. A TAR may be filled out and submitted by the service provider or the PCP.
All providers and specialists should seek Prior Authorization for any services and procedures listed in Attachment A: Services Requiring Treatment Authorization Requests.
Additionally, non-panel providers and non-contracted specialists should seek Prior Authorizations before rendering office visits or office consultations.
Please also refer to Attachment B: Prior-Authorization Exemptions List for a list of services that do not require Prior Authorization. You may also refer to the 1-page NEMS MSO Utilization Management Authorization Grid for a quick reference of all services that need or do not need Prior Authorizations.
Claims Payment Methodology
For NEMS panel providers/contracted specialists, NEMS will pay for authorized claims according to the specific terms of each physician, hospital, or physician group contract.
For non-panel providers/non-contracted specialists, NEMS will pay for authorized claims according to the NEMS Usual, Customary & Reasonable (UCR) rate.
All claims for services submitted without the required prior authorizations will be processed as Administrative Denials for reimbursement. A Remittance Advice will be sent to the service provider with a detailed explanation of the claims adjudication, and guidelines for a provider claims dispute.
If an Advanced Outpatient Procedure is required on an urgent basis, or Prior Authorization cannot be obtained because it is outside of NEMS MSOís normal business hours, the service may be performed, and authorization should be requested retroactively within two (2) business days of the service. Documentation must include an explanation as to why the procedure was required on an urgent basis and/or could not be pre-authorized during NEMS MSOís normal business hours. Please refer to the "Retroactive Authorization Requests" section below.
Retroactive Authorization Requests
NEMS may issue a retroactive authorization to a provider for services rendered if:
- The service is medically necessary and appropriate at time of treatment
- The service is related to continuity of care
Providers should submit a Treatment Authorization Request (TAR) form, with "Retro Request" indicated on the form within two (2) business days of the service. The TAR form should be faxed or mailed to the NEMS MSO Utilization Management Department along with the patientís consultation reports, treatment notes and/or surgical reports for clinical consideration.
The turnaround time for issuing a retro authorization is five (5) business days after receipt of the request. The TAR form will be faxed back to the provider once a decision on approval or denial is made.
Attachment A: Services Requiring Treatment Authorization Requests
Services that require Treatment Authorizations prior to the rendering of care include:
- Ambulance Transport (and other non-emergency transport)
- Ambulatory Surgery Services
- Audiological Services
- Bone Density Studies
- Cardiac Catheterization
- Cardiac Rehabilitation
- Chemical Dependency Services
- Child Development Services
- CT Scans
- Durable Medical Equipment (DME), including oxygen, prosthetics and corrective appliances
- Gamma Immune Therapy
- Holter Monitoring
- Home Health / Home Infusions Services
- Hospice Care
- Hospital Admissions (elective)
- Laboratory, Radiology Procedures costing over $300
- Magnetic Resonance Imaging (MRI scans)
- Maternity hospital admissions outside of standard care
- Mental Health Services
- Nuclear Medicine Studies
- Nutritional Counseling (all types)
- Obstetric Procedures and/or Tests Outside of Standards
- Occupational Therapy / Physical Therapy (outpatient)
- Office Procedures over $300
- Ophthalmic Procedures (excluding office-based procedures)
- Orthotics and Prosthetics
- Out-of-Network Services
- Pentamidine Treatment
- Podiatric Surgery (including office-based surgery)
- Psychological Testing
- Pulmonary Function Tests (other than baseline spirometry)
- Radiation Therapy
- RAST Testing
- Rehabilitation Services
- Renal Dialysis
- Respiratory Therapy (outpatient)
- Skilled Nursing and Intermediate Care
- Sleep Monitoring / Sleep Studies
- Speech Therapy
- Treadmill Stress Test
- Ultraviolet Light Treatment
- Ultrasounds (hospital based Ėexcept for OB)
Attachment B: Prior-Authorization Exemptions List
Services that do not require Treatment Authorizations prior to the rendering of care include:
- Sensitive Services
- Medi-Cal members may self-refer to any out-of-network providers for pregnancy testing, family planning services, HIV testing, and treatments of sexually transmitted diseases. For other lines of business, members may self-referred to NEMS panel providers for sensitive services.
- Abortion services is excluded in this category, please refer to the Abortion Services section for detail.
- Members may self-refer to Department of Public Health immunization clinics under "urgent need" conditions.
- Emergency Services
- Authorization is not required for emergency situations as defined by the examining physician, assessment and treatment must proceed until the patient is stabilized.
- Routine and non-urgent cares received in an emergency room setting require approval by the PCP.
- Out-of-Area emergency services will be covered with submission of medical documentation to proof the emergent medical condition.
- Routine and follow up care related to the emergency services should be directed back to the patientís PCP office.
Panel Providers / Contracted Specialists Only:
- Abortion Services
- Members may self-refer for outpatient abortion services if under 20 gestational weeks of pregnancy, but must see a provider that is contracted with NEMS Medical Group.
- Prior authorization stating medical justification is required if abortion service over 20 gestational weeks of pregnancy.
- CHDP/EPSDT Preventive Services
- EPSDT and CHDP services provided by PCP, FQHC, community Clinic, DPH per EPSDT/CHDP periodicity schedules and guidelines, no prior-authorization is required.
- OB/GYN Services
- Members may self direct to any NEMS Medical Groupís affiliated obstetrician/gynecologist for gynecological and obstetrical services.
- Prior-authorization is required for hospital admission and testing outside of standards.
- Standing Referrals to Specialty Care
- A member with a life threatening, degenerative and disabling condition is eligible for a standing referral that allows the specialist to act as the care coordinator in lieu of the PCP.
- People with HIV/AIDS are eligible for a referral to an AIDS specialist who acts as the coordinator of care.
- The member is directed back to the PCP for unrelated problems.
- Tuberculosis Care
- Tuberculosis screening, testing, and treatment, does not require prior authorization, unless hospitalization is needed.
- Well Woman Care
- Services provided according to ACOG guidelines by a NEMS Medical Groupís affiliated providers with emphasis on preventive screening, including routine Pap smear, breast exam, and mammography, does not require prior approval.