Prior Authorization Under Primary Care Case Management Contracts.

(a)

All Medi-Cal covered services not included in the PCCM plan contract as part of the capitated services provided to a PCCM plan member are subject to prior authorization by the member's PCCM plan except:

(b)

No payment shall be made by the Department for Medi-Cal covered services rendered by a nonplan provider to a PCCM plan member when the provider failed to obtain the required prior authorization from the PCCM plan.

(c)

The Department shall recoup payments erroneously made to a provider for Medi-Cal covered services rendered to a PCCM plan member without proper authorization.

(d)

The PCCM plan medical director may delegate responsibility for authorizing medical services to another plan physician or subcontracting physician. The PCCM plan and medical director retain final responsibility for all authorizations or denials of Treatment Authorization Requests for all Medi-Cal noncapitated services rendered to PCCM plan members. The physician accepting the delegation of authority shall agree in writing to: