Prior Authorization Required For All Non-Par Laboratory Testing

Date: 12/01/16

As of January 1, 2017, all non-par laboratory testing will require prior authorization, with certain exceptions outlined below. This change brings laboratory testing into compliance with our existing policy:

As the Medical Home, California Health & Wellness providers coordinate all healthcare services for our members. All out-of-network laboratory services (excluding laboratory services in the emergency room, sensitive services and specific routine labs conducted in a physician’s office or clinic. require prior authorization.

Prior authorization request must come from the ordering physician, not the rendering laboratory. This policy applies to all California Health & Wellness providers, including Behavioral Health providers.

To submit a request for Prior Authorization, contact our Utilization Management department via telephone at 877-658-0305, via fax at 866-724-5057, or by logging into our secure Provider Portal. Please ensure that you have the appropriate supporting clinical information to request an authorization.

For more information, look through our website or contact your Provider Relations Representative at 877-658-0305.

Benefits of PAR Laboratory Testing

Contractual HBR incentives:

Using our in-network laboratories such as Quest and LabCorp for services will result in lower overall costs, because California Health & Wellness has national in-network lab rates that are below our out-of-network lab rates.

Provider Incentives tied to HEDIS rates:

Using our in-network laboratories such as Quest and LabCorp for services will result in your patients having higher compliance rates with key HEDIS measures tied to lab results such as HbA1c diabetic testing as we have a robust informatics pipeline in place between these labs and our electronic data warehouse.