Pre-approval

For some types of care, your PCP or specialist will need to ask L.A. Care for permission before you get the care. This is called asking for prior authorization, prior approval, or pre-approval. It means that L.A. Care must make sure that the care is medically necessary or needed.

Medically Necessary services are reasonable and necessary to protect your life, keep you from becoming seriously ill or disabled, or reduce severe pain from a diagnosed disease, illness or injury. For Members under the age of 21, Medi-Cal services includes care that is medically necessary to fix or help relieve a physical or mental illness or condition.

The following services always need pre-approval (prior authorization), even if you get them from a provider in the L.A. Care network:

  • Hospitalization, if not an emergency
  • Services out of the L.A. Care service area, if not an emergency or urgent
  • Outpatient surgery
  • Long-term care at a nursing facility
  • Specialized treatments
  • Medical transportation services when it is not an emergency. Emergency ambulance services do not require pre-approval.
  • Major organ transplant

Under Health and Safety Code Section 1367.01(h)(1), L.A. Care will decide routine pre-approvals (prior authorizations) within 5 working days of when L.A. Care gets the information reasonably needed to decide.

For requests in which a provider indicates or L.A. Care determines that following the standard timeframe could seriously endanger your life or health or ability to attain, maintain, or regain maximum function, L.A. Care will make an expedited (fast) pre-approval (prior authorization) decision.
L.A. Care will give you notice as quickly as your health condition requires and no later than 72 hours after getting the request for services.

Pre-approval (prior authorization) requests are reviewed by clinical or medical staff, such as doctors, nurses and pharmacists. L.A. Care does not pay the reviewers to deny coverage or services.
If L.A. Care does not approve the request, L.A. Care will send you a Notice of Action (NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with the decision.
L.A. Care will contact you if L.A. Care needs more information or more time to review your request.

You never need pre-approval (prior authorization) for emergency care, even if it is out of the network and out of your service area.
This includes labor and delivery if you are pregnant.

You do not need pre-approval (prior authorization) for sensitive services, such as family planning, HIV/AIDS services, and outpatient abortions.
For questions about pre-approval (prior authorization), call Member Services at 1-888-839-9909 (TTY 711).