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' First Care Panel is extended to all MPN providers. The Prior Authorization Program is per claim and not per provider.

Please see below information specific for the Los Angeles World Airports (LAWA) Program, managed by Intercare.

General Instructions

Utilization Review and Request for Authorization (RFA):

• A. No 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:

·       Intercare Utilization Review (UR): Fax number: 916-520-8570 e-mail Address: rfa@intercareins.com

• C. No RFA's should be sent to Intercare’s Managed Care provider. 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 Intercare for the 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 all or any accepted body part(s) and must be provided by Intercare’s Managed Care Provider, InterMed Cost Containment Services.

·       1.  Diagnostic Tests:  Streamline:  How to refer to STREAMLINE: P: 855-877-9292; F: 855-877-9595; : referral@streamlineworkcomp.com  website; streamlineworkcomp.com

• MRI
• CT Scan
• X-rays
• EMG/NCS

• 2. Physical Medicine: No Preferred Provider in Place:

• Physical Therapy – 12 sessions
• Occupational Therapy – 12 sessions
• Acupuncture – 12 sessions
• Chiropractic  – 12 sessions
• Aquatic Therapy – 6 sessions

• 3. Medications:  Optum Pharmacy Benefit Management (PBM)

• 90 Days of prescription drugs per Medical Treatment Utilization Formulary with Optum. All prescriptions go through the Optum program.  Questions call Pharmacy Help Desk: 1-800-964-2531

·       4. Durable Medical Equipment: SMS National, Email Referrals to: referrals@smsnational.net, Phone: 1-800-404-9761

DO NOT ORDER NAME BRANDS FOR ANY DURABLE MEDICAL EQUIPMENT.

·       Non-surgical basic equipment:

o   Splints – Off the Shelf

o   Braces – Off the Shelf

o   Walkers

o   Standard wheelchair rental

o   Slings

o   Hot and cold packs

·       Post-Surgical Discharge DME such as:

o   Cold Packs

o   Ankle Foot Orthotics, Walking cane, Crutches

o   Braces, Walker

o   Standard Wheelchair rental, Tub/Shower, Chair

o   3-1 commode

• 5. Office Visits & Specialty Referrals

• Routine Office Visits and Follow Ups
• Specialty Consult Referral – Within the MPN only
• 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