1. (a) All Medi-Cal covered services not included in the PCCM plan contract as part of the capitated services provided to a PCCM plan member are subject to prior authorization by the member's PCCM plan except:

   1. (1) Dental Services.
   2. (2) Emergency services as defined in section 51056(a).
   3. (3) Those services determined by the Department to be exempt from PCCM plan prior authorization requirements as specified in each PCCM plan contract. In determining which services shall not be subject to prior authorization, the Department shall consider the factors specified in section 51159(a).
2. (b) No payment shall be made by the Department for Medi-Cal covered services rendered by a nonplan provider to a PCCM plan member when the provider failed to obtain the required prior authorization from the PCCM plan.
3. (c) The Department shall recoup payments erroneously made to a provider for Medi-Cal covered services rendered to a PCCM plan member without proper authorization.

4. (d) The PCCM plan medical director may delegate responsibility for authorizing medical services to another plan physician or subcontracting physician. The PCCM plan and medical director retain final responsibility for all authorizations or denials of Treatment Authorization Requests for all Medi-Cal noncapitated services rendered to PCCM plan members. The physician accepting the delegation of authority shall agree in writing to:

   1. (1) Review and either defer, authorize, or deny Treatment Authorization Requests for Medi-Cal covered noncapitated services to be rendered to PCCM plan members in accordance with section 51003.
   2. (2) Respond to inquiries from the fiscal intermediary regarding Treatment Authorization Requests which have been submitted for PCCM plan members.

Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14088, 14088.4 and 14177, Welfare and Institutions Code.

History

1. New section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-9-90.

2. New section refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 11-6-90.

3. Request to readopt section on an emergency basis pursuant to Government Code section 11346.1 granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 11-6-90 order transmitted to OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).

5. New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No. 18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or emergency language will be repealed by operation of law on the following day.

6. Certificate of Compliance as to 3-25-91 order including amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92, No. 1).