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.

General Instructions

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

• 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

Tristar Risk Management UR designated Fax at 626-407-0415

AIMS UR designated Fax at 909-348-0919

Elite UR designated FAX at 951-676-7258

• 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.

• 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 all or any accepted body part(s) and must be provided by the City of Los Angeles' Contracted Managed Care Providers listed below.

• Diagnostic Tests: One Call Medical (866) 557-8670 

• MRI
• CT Scan
• X-rays
• EMG/NCS

• Physical Medicine: Med Risk (855) 806-9754

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

• Medications: Express Script (800) 945-5951

• 90 Days of prescription drugs per Medical Treatment Utilization Formulary.
• Point of Entry Occupational Medicine Clinics only, may dispense first fill up to 7 day supply per the MTUS formulary. A script must be issued for all medications past initial 7 day supply to be filled by PBM.

• Durable Medical Equipment:  Optum (800) 419-7191

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

• 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.

• Psychology

• 6 Psychological Visits for an accepted psych claim

• 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.

• Other Services

• Tetanus Shot if over 10 years from the last injection
• Blood Tests:  CBC, BMP, UA, CXR, EKG (only if heart claim)