The NEMS MSO Utilization Management (UM) team reviews treatment authorization requests (TARs) submitted by providers. Services that require prior authorization varies between plans. TARs, and the supporting clinical documentation, may be submitted by fax or through the NEMS MSO Provider Portal (EZ-NET).
The UM team uses evidence-based clinical criteria and makes UM decisions timely.
The Medi-Cal turnaround time for decisions and notifications are as follows:
| TAR Type | Receipt | Decision | Member Notification of Final Decision | Provider Notification of Final Decision |
|---|---|---|---|---|
| Non-Urgent Preservice (No Extension) |
Day 0 | Within 5 business days from Day 0 | In writing within 2 business days from the decision | Initial Notification: Within 24 hours of decision by email or fax
Written Notification: Within 2 business days from the decision |
| Non-Urgent Preservice (Extension) |
Day 0 | Up to 14 calendar days from Day 0 | In writing within 2 business days from the decision, not to exceed 14 calendar days from Day 0. | Initial Notification: Within 24 hours of the decisions by email or fax
Written Notification: |
| Urgent Preservice | Day 0 | 72 hours from Day 0 | In writing within 24 hours from the decision, but not to exceed 72 hours from Day 0 | Initial Notification: Within 24 hours of decision by email or fax
Written Notification: Within 2 business days from the decision, but not to exceed 72 hours from Day 0 |
| Concurrent (inpatient) | Day 0 | 72 hours from Day 0 | In writing within 72 hours or 2 business days from the decision, whichever is earlier | Initial Notification: Within 24 hours of decision by email or fax, but not to exceed 72 hours from Day 0
Written Notification: In writing within 72 hours or 2 business days from the decision, whichever is earlier |
| Retrospective | Day 0 | 30 calendar days from Day 0 | In writing within 30 calendar days from Day 0 | In writing within 30 calendar days from Day 0 |
| Pharmaceutical | Day 0 | 24 hours from Day 0 | In writing within 24 hours from Day 0 | In writing within 24 hours from Day 0 |
The Medicare turnaround time for decisions and notifications are as follows:
| TAR Type | Decision | Member Notification of Final Decision | Provider Notification of Final Decision |
|---|---|---|---|
| Non-Urgent Preservice (No Extension) |
Within 14 calendar days of receipt of request | In writing within 14 calendar days of request | In writing within 14 calendar days of request |
| Non-Urgent Preservice (Extension) |
Within 28 calendar days of receipt of request | Extension Notice: In writing within 14 calendar days of request
Decision Notice: In writing within 28 calendar days of request |
Extension Notice: In writing within 14 calendar days of request
Decision Notice: In writing within 28 calendar days of request |
| Urgent Preservice (No Extension) |
Within 72 hours of receipt of request | For Approved Services: Within 72 hours of request by phone or written notice.
For Denied Services: Verbally within 72 hours of request followed by a written notice within 3 calendar days of verbal notification. |
For Approved Services: Within 72 hours of request by phone or written notice.
For Denied Services: Verbally within 72 hours of request followed by a written notice within 3 calendar days of verbal notification. |
| Urgent Preservice (Extension) |
Within 14 calendar days of receipt of request | Extension Notice: In writing within 72 hours of request.
For Approved Services: Within 14 calendar days of request by phone or written notice. For Denied Services: Verbally within 14 calendar days of request followed by a written notice within 3 calendar days of verbal notification. |
Extension Notice: In writing within 72 hours of request.
For Approved Services: Within 14 calendar days of request by phone or written notice. For Denied Services: Verbally within 14 calendar days of request followed by a written notice within 3 calendar days of verbal notification. |
| Non-Urgent Preservice (Part B Drugs) | Within 72 hours of receipt of receipt of request | Within 72 hours of receipt of request | Within 72 hours of receipt of request |
| Urgent Preservice (Part B Drugs) | Within 24 hours of receipt of receipt of request | Orally within 24 hours of receipt of request, followed by a written notice within 24 hours of oral notification | Orally within 24 hours of receipt of request, followed by a written notice within 24 hours of oral notification |
Medi-Cal Plan Authorization Requirements
| Authorization Required | No Authorization Required |
|
Authorization for the below services are not processed by NEMS MSOPlease contact the entities responsible for the following services:
|
Reviewed 7/30/2024
Medicare Advantage Plan Authorization Requirements
| Authorization Required | No Authorization Required |
|
Authorization for the below services are not processed by NEMS MSOPlease contact the entities responsible for the following services:
|
Reviewed 5/28/2024
| Authorization Required | No Authorization Required |
|
Authorization for the below services are not processed by NEMS MSOPlease contact the entities responsible for the following services:
|
Reviewed 5/28/2024
| Authorization Required | No Authorization Required |
|
Authorization for the below services are not processed by NEMS MSOPlease contact the entities responsible for the following services:
|
Reviewed 5/28/2024
Important Notice:
- NEMS MSO reserves the right to review and modify authorization requirement based on established criteria and/or community standards of practice
- Payment is contingent upon eligibility at the time of service
- Provider is responsible for verifying member eligibility prior to rendering services