Utilization controls that may be applied to the services set forth in Section 14132 which are subject to utilization controls shall be limited to:
(a) Prior authorization, which is approval by a department consultant, of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Prior authorization includes authorization for multiple services which are requested and granted on the basis of an extended treatment plan where there is a need for continuity in the treatment of a chronic or extended condition.
(b) Postservice prepayment audit, which is review for medical necessity and program coverage after service was rendered but before payment is made. Payment may be withheld or reduced if the service rendered was not a covered benefit, deemed medically unnecessary or inappropriate. Nothing in this subdivision shall supersede the claims processing deadlines provided by Section 14104.3.
(c) Postservice postpayment audit, which is review for medical necessity and program coverage after service was rendered and the claim paid. The department may take appropriate steps to recover payments made if subsequent investigation uncovers evidence that the claim should not have been paid.
(d) Limitation on number of services, which means certain services may be restricted as to number within a specified time frame.
(e) Review of services pursuant to Professional Standards Review Organization agreements entered into in accordance with Section 14104.
(Amended by Stats. 1979, Ch. 373.)
Last modified: October 25, 2018