Authorizations and Referrals

Non-Emergency Services Requiring Prior Authorization:

• Non-emergency out of area care (outside of L.A. County)
• Out of network care, services not provided by a contracted network doctor
• Inpatient admissions, post-stabilization/nonemergency/elective
• Inpatient admission to skilled nursing facility or nursing home
• Outpatient hospital services/surgery
• Outpatient, non-hospital , such as surgeries or sleep studies
• Outpatient diagnostic services, minimally invasive or invasive such as CT Scans, MRIs, colonoscopy, endoscopy, flexible sigmoidoscopy, and cardiac catheterization

Services That Do Not Require Prior Authorization

• Emergency Services, whether in or out of L.A. County but within the continental USA (except for care provided outside of the United States which is subject to retrospective review).
• Emergency Care provided in Canada or Mexico is covered
• Urgent care, whether in or out of network
• Mental health care and substance use treatment
• Routine Women’s health services – a woman can go

directly to any network provider for women’s health care such as breast or pelvic exams

• This includes care provided by a Certified Nurse
• Midwife/OB-GYN and Certified Nurse Practitioners
• Basic prenatal care – a woman can go directly to any network provider for basic pre-natal care
• Family planning services, including: counseling, pregnancy tests and procedures for the termination of pregnancy (abortion)
• Treatment for Sexually Transmitted Diseases, includes: testing, counseling, treatment and prevention
• Emergency medical transportation

• Urgent Referrals: within 72 hours from receipt of all necessary information to make the determination.
  • The provider notifies the utilization management department or calls the medical director or on-call physician that the patient is being sent for emergency services.
  • The provider or designee must ensure that the required paperwork is completed.
• Non-Emergency Referrals: within 5 working days from receipt of all necessary information to make the determination.
  • The provider or designee completes a referral for service form.
  • The form and the medical record/pertinent information are forwarded to the utilization management department.
  • Eligibility and benefits are checked, and the referral and accompanying data is forwarded to the UM Nurse for review.
  • If criteria is not met, UM Nurse forwards to Medical Director for further review.

Timeliness of UM Decision Making:

• For urgent concurrent review (decisions), SCMC makes decisions and gives electronic or written notification of the decision to practitioners and members within 24 hours of the request. Notification must be oral, unless the practitioner or member requests written notification.
• For urgent preservice decisions, SCMC makes decisions and gives electronic or written notification of the decision to practitioners and members within 24 hours of the request. Notification must be oral, unless the practitioner or member requests written notification.
• For nonurgent preservice decisions, SCMC makes decisions and gives initial notification to the practitioner within 24 hours of the decision. Member notification is within 2 business days of the decision for approvals. Written/Electronic notification of a denial to the practitioner and member is done within 2 business days of making the decision
• For nonurgent post service decisions, SCMC makes decisions and gives electronic or written notification of the decision to practitioners and members within 30 calendar days of the request.

UM Decision Notification to Providers:

• Physicians within SCMC are given telephone notification. Written notification is available within SCMC’s EMR for all in house physicians.
• Contracted physicians outside of SCMC are given notification of UM decisions by mail and by telephone.

Consultation Communication between Primary Care and Specialist Physician:

• EMR is a centralized file for all SCMC patients. Specialist consultations are available in EMR for all SCMC Physicians to review. The PCP will review the specialist progress note(s) and acknowledge on the PCP progress note once reviewed. (i.e. “Specialist note reviewed” Yes or N/A will be checked as appropriate by the PCP.)

You may submit request for service by fax to: (818) 683-1076 along with medical records/pertinent information. You may call to verify that your fax was received (818) 504-4569.

• You may submit request for service by fax to: (818) 683-1076 along with medical records/pertinent information. You may call to check the status of your request at (818) 504-4569.

Retrospective Review: Cover letter, Claims & Medical Records must be submitted for review.

Please mail retrospective and regular claims to:

Serra Medical Group

9375 San Fernando Rd.

Sun Valley, CA 91352

Non-contracted providers must have a signed Release of Information form by the member in order to share patient information.

All authorizations will be processed in compliance with ICE Guidelines and Time Frames.

Affirmative Statement available upon request and available via web (www.serramedicalgroup.com) SMG UM decisions are made using Apollo’s Medical Review Criteria. Utilization Management Criteria is available to the public and practitioners upon request. Physician reviewer is available by phone to physicians to discuss determinations by calling 818-683-1076.