CITY OF LOS ANGELES WORKERS’ COMPENSATION DIVISION

PRIOR AUTHORIZATION PROGRAM

 

On July 1, 2010 the City of Los Angeles implemented a Prior Authorization Program (PAP). All treatment requests must follow the Title 8 CCR § 9792.20-9792.22 MTUS criteria.

The City of Los Angeles’ Prior Authorization Program (PAP) is extended to all MPN providers. The Prior Authorization Program is per claim and not per provider.

 

General Instructions

A.    No Request for Authorization (RFA) needed for the services or treatments provided to the patient under the PAP program.

 

 

B.    A PR-2 or 5021 must be submitted and indicate clearly that the services and procedures rendered supports the medical necessity of the treatment provided. Fax the documents to:

 

City of Los Angeles UR designated Fax at 213-473-3377

Intercare UR designated Fax at 818-476-4402 – LAPD Sworn Claims Sedgwick UR designated Fax at 833-784-2352 – LA Fire Claims Elite UR designated FAX at 951-676-7258 – LAPD Civilian Claims

 

C.   No RFA’s should be sent to the City of LA Contracted Managed Care Providers. A prescription, doctor’s medical report or notification form should only be used to inform the providers of the treatment or tests needed.

 

D.   No Certification Letter will be sent by the City of Los Angeles claims administrators for those procedures which fall under this program.

 

The Prior Authorization Program will include the following procedures or ancillary services:

 

PLEASE NOTE: Initial diagnostic tests or procedures can be done to any accepted body part(s) and must be provided by the City of Los Angeles’ Contracted Managed Care Providers listed below.

 

 

1.    Diagnostic Tests: MIS Phone: 800.894.4674/Fax: 714-736-9494 Email: schedule@mis4wc.com

a.    MRI

b.    CT Scan

c.    X-rays

d.    EMG/NCS

 

2.    Physical Medicine: Medrisk (800)225-9675

a.    Physical Therapy – 12 sessions

b.    Occupational Therapy – 12 sessions

c.     Acupuncture – 12 sessions

d.    Chiropractic – 12 sessions

e.    Aquatic Therapy – 6 sessions

 

3.    Medications: myMatrixx (800) 945-5951

·    Prodigy – Specialty/Brand/IV  Medications – 888-526-8002

a.    90 Days of prescription drugs per Medical Treatment Utilization Formulary.

b.    Point of Entry Occupational Medicine Clinics may dispense first fill only.

c.     Prodigy handles all specialty, brand, and IV medications.

 

 

 

4.    Durable Medical Equipment: - Please refer based on claim office.

 

LA City Office

•       Optum – A-H

•       Convergence Care – I–L

•       Century Pacific – M-Z

                         

                          Intercare/Elite

•       Optum – A-H

•       Century Pacific I-Z

 

                          Sedgwick

•       Direct Care Management – A-H

•       Optum – I-Z

§   

Optum (888) 880-9656

Century Pacific – (800) 239-4119

Convergence Care – 800-929-3011

Direct Care Management – 888-478-4264

Non-surgical basic equipment:

Splints – Off the Shelf Crutches

Braces – Off the Shelf Canes

Walkers

Standard wheelchair rental Walking boots

Slings

Hot and cold packs

 

Post-Surgical Discharge DME such as: Cold Packs

Ankle Foot Orthotics Walking cane Crutches

Braces Walker

Standard Wheelchair rental Tub/Shower Chair

3-1 commode

5.  Office Visits & Specialty Referrals

·      Routine Office Visits and Follow Ups

·      Specialty Consult Referral

·       When diagnosis of hernia is made on initial visit, refer to General Surgeon immediately.

 

6.    Psychology

·      6 Psychological Visits for an accepted psych claim

7.  Corticosteroid Injections (Non-diabetic patients)

 

·       Elbow: Up to 3 injections in cases of severe pain from epicondylitis. Improvement must be shown after initial injection.

·       Knee: Up to 3 injections if the patient has osteoarthritis. Improvement must be shown after initial injection.

·       Shoulder: Up to 3 injections if the patient has rotator cuff disease. Improvement must be shown after initial injection.

·       Fingers: Up to 3 injections for Trigger Finger. Improvement must be shown after initial injection.

 

8.    Other Services

·      Tetanus Shot if over 10 years from the last injection

·      Blood Tests: CBC, BMP, UA, CXR, EKG (only if heart claim)

 

 

Updated 8/2025