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Service Authorizations

Overview

Some services require authorization in order to be billed to Medi-Cal. This is generally covered by BHIN 19-026. Some services should be authorized prior to the service being provided, some concurrently, and some may be authorized after the service has already been rendered.

The workflow of authorizations may depend on the service being authorized, though the main workflow is that a direct-service staff requests authorization from the county, and a county staff reviews the request and makes a decision whether to approve or deny the request. This means that what was requested must be documented clearly, as what is ultimately authorized may or may not match what was requested.

CalMHSA has developed a method of handling this request-approval workflow using the “Service Request” screens. This includes a list page, a corresponding widget, and a details page. Depending on whether the user is a “requester” or a “reviewer”, the screens will look a little different.

List Pages:

  1. Service Request List (Client) – shows all service requests for the selected client that the logged in user has created
    1. If the user is a supervisor, they will also see all requests made by any users that they supervise (per Staff Details)
  2. My Service Request List (My Office) – shows all service requests that the logged in user has created
    1. If the user is a supervisor, they will also see all requests made by any users that they supervise (per Staff Details)
  3. Service Request – Review/Approval List (Client) – shows all service requests for the selected client that are assigned to the logged in user OR is assigned to a workgroup that the user is a part of
    1. If the user is a supervisor, they will also see all requests assigned to any users that they supervise (per Staff Details)
  4. My Service Request – Review/Approval List (My Office) – shows all service requests that are assigned to the logged in user OR is assigned to a workgroup that the user is a part of
    1. If the user is a supervisor, they will also see all requests assigned to any users that they supervise (per Staff Details)

Widgets:

  1. Service Requests
    1. Supervisee Service Requests
  2. Service Requests for Review/Approval
    1. Supervisee Service Requests for Review/Approval

Detail Pages:

  1. Service Request Detail – This will show only the “Request” and “Attachments” tabs.
  2. Service Request – Review/Approval Detail – This will show all 5 tabs

CalMHSA will be granting the “LPHA/Clinician” and “Non-LPHA” user roles with “requester” screens and widgets. CalMHSA will be granting “Medical Records/Quality Assurance” and “Billing” user roles with “reviewer” screens and widgets.

There are 2 other additional permissions that need to be granted to “reviewers”:

  1. Staff List: Approve Service Request
  2. Screens: Authorization Reasons popup

Note that in QA systems, “Authorization Reasons popup” may simply be named “Authorization Reasons”. Compare the Screen URL to that in your Prod system to find the correct version. It should be “/Modules/ServiceRequest/Details/…”.

CalMHSA will be granting the “County Affiliate Sys Admin” user role all authorization related permissions (both requester and reviewer permissions).

As always, counties can create their own custom user roles to expand on CalMHSA’s default options.

Workflow

To create a new service authorization request, the requester will need to go to the appropriate list page and click the New icon. This will take them to the appropriate service request details screen. They will enter in the details of their authorization request, add any attachments that they feel justify the request, and submit to the reviewer.

The reviewer will see any requests assigned to them via the widget. Clicking into the widget will bring them into the list page where they can select the request they want to review. On the Approval tab, the reviewer reviews the request and makes changes to the authorization details as necessary before finalizing the result of the review.

If the reviewer needs additional information from the requester in order to make their decision, they can send this back to the requester for more details. This will show up on the requester’s widget as “Awaiting Additional Information”. The requester can then navigate back to the specific service request where they will be able to only edit the “Justification” field and what’s attached to the request. They then re-submit the request. This back and forth can be done any number of times.

The authorization details that are entered and finalized in this Service Request – Review/Approval Detail screen by the reviewer are then pushed to SmartCare’s core authorization screen, thereby creating the billing authorization. This allows CalMHSA to utilize the built-in authorization functionality while still limiting what a requester has access to. If a county has set up billing rules to keep a service from being billed without authorization, the nightly billing job will check for an authorization before the service can become a charge. As services become charges, the authorization functionality will track how many units are authorized and how many have been used.

The billing rules for this are set up at the Plan level. This means that if any of the client’s coverage plans requires an authorization for the service rendered, then the service cannot become a charge. While there are a list of services that require authorization, the County Workgroup assigned to this initiative determined that it would be better to allow counties to set these billing rules up themselves, so as not to force counties into using this functionality by a certain timeframe.

County Referrals – Authorizations Not Requested

Sometimes the county refers a client to a particular service without a provider making an initial request. This can be done via the Service Request – Review/Approval Detail screen in the Approval tab. A user with the correct “reviewer” permissions can simply enter an authorization in the Approval tab without entering anything on the Request tab.

Re-Authorization Requests

An initial authorization will eventually run out of units or time. A re-authorization request is generally requested if the client still has need of those services. The re-authorization request process is no different than the initial request process.

Workflow Related Articles

Requester Articles can be found on the Clinical Documentation under the Care Coordination section:

How to Create a Service Authorization Request

Reviewer Articles can be found on the Billing and QA/QI pages

How to Process Service Authorization Requests

Setup

Most setup will be completed in production environments by CalMHSA. As mentioned above, the billing rules will need to be set by the county themselves. All setup information can be found on the System Administration Documentation page under the Billing Administration section under sub header “Authorization Set-Up”.

Setup Related Articles

Known Issues & Planned Design Updates

These are the concerns that were brought up during the testing phase either by CalMHSA or counties involved in the County Workgroup. The counties felt that these issues were minor enough to move forward, feeling that the benefits of the new development outweighed the potential issues. Some are items that will require a design update, and CalMHSA will be putting in this request as deemed necessary, as prioritized against all other enhancement requests.

  1. Reviewer list page and widget seem to be working oddly.
    • The My Service Requests – Review/Approval List page should show all requests that were assigned to the logged in user OR assigned to a workgroup the user is associated with. Filters don’t seem to impact this, and requests assigned to a workgroup can only seem to be viewed by making the selection in the widget. Once on the list page, “Apply Filter” seems to clear out this selection. CalMHSA is working with Streamline on a fix.
    • UPDATE 4/11/2025: Navigating to the list page from the widget will show only those requests assigned to either the staff user OR the workgroup, depending on what was selected in the widget. We are working on the ability to have the filters include an “ALL” and a “NONE” (blank) option, but do not have an ETA. Please see this matrix for details on what results will be expected when the staff/workgroup filters are used once this new functionality is developed. [Zendesk ticket # 63621]
    • UPDATE 4/11/2025: Please also note that your workgroups will require CDAG in order to show on this list page. If workgroups aren’t showing, add the appropriate CDAGs and re-load the list page.
  2. A user with “reviewer” permissions who submits a request can review and approve that request, even though they are not assigned to review the request.
    • We expect that anyone given “reviewer” permissions will not approve requests that they shouldn’t be approving. We are considering making a change where only the assigned staff or assigned workgroup would be able to make edits to the approval tab. The county workgroup indicated that this was very low priority, as the reviewers would generally always be in a position to approve any requests that they can see.
    • UPDATE 4/11/2025: We are not pursuing this change at this time. [Zendesk ticket # 53611]
  3. Attachment tab allows a reviewer to see more documents than just those attached.
    • When a requester attaches documents to a request, the documents are shown in the list as attached. When a reviewer clicks on one of the documents, the “Attach Documents” window pops up. This is the same window that the requester used to attach documents. The reviewer can see the documents that are already attached and use the window to preview them. However, this does not stop the reviewer from previewing documents that are not attached to the request. We expect that anyone given “reviewer” permissions will us a minimum-necessary method of viewing documents. We are exploring ways to change this functionality so that only the attached documents are visible.
    • UPDATE 4/11/2025: Streamline is working on this. No ETA. [Zendesk ticket # 56011]
  4. Program fields not pushing to the core authorization screen.
    • This is occurring because the core authorization screen requires that a client be associated with a program in order to select that program from the dropdown. CalMHSA is working with Streamline to address this issue. In the meantime, we recommend that reviewers use the Disposition section to add the program that’s being approved and saving this before generating the authorization. This will put the client in requested status for this program, assuming the county is using this functionality.
    • UPDATE 4/11/2025: Streamline is working on this. No ETA. [Zendesk ticket # 56288]
  5. Sending a request back for more information requires all fields to be completed.
    • When a reviewer needs to send a request back to the requester for more information, the reviewer is still required to select a Status, a Status Reason, and an Approved Program. CalMHSA is requesting that this be updated to at least not require an Approved Program. The Status may be changed to Pended and the Reason be selected by the reviewer, which at least makes some sense to indicate that the reviewer has at least reviewed the authorization but needs more information. Leaving this blank may indicate that the reviewer has not even reviewed this request.
    • UPDATE 4/11/2025: Is in the Feb 2025 MSP build. See the Release Notes section on the System Administration page for the planned deployment schedule. [Zendesk ticket # 63625]
  6. Add “Submitted” and “Re-Submitted” as rows in the Service Request Widget.
    • The Service Request widget currently only shows statuses in which the requester has an active task. “Pending” means the request hasn’t been submitted yet and “Awaiting Additional Information” means it’s been sent back to the requester for additional information. However, the county workgroup indicated it would be helpful for the user to be able to see “Submitted” and “Re-Submitted” as options as well. These would indicate that the requester has authorizations that have not yet been completed by reviewers.
    • UPDATE 4/11/2025: Streamline is working on this. Will also include updates to the supervisor version of this widget. No ETA. [Zendesk ticket # 63605]
  7. A requester cannot click into the authorization list after submitting to view what was submitted.
    • Once a requester has submitted the request, all fields on the Request and Attachments tabs lock down. This includes the ability to select an authorization from the Auth List section. We are requesting that the radio buttons in the Auth List will be selectable so that a user can see exactly what was requested. They will still not be able to edit the request in any way.
    • UPDATE 4/11/2025: FIXED in production (September MSP Hotfix build). [Zendesk ticket # 63604]
  8. Add a unit description once the Auth Code is selected.
    • Auth Codes use “units” which are a combination of units such as “days” or “minutes” and a number. For example, an Auth Code “unit” can be set to “60 minutes”. CalMHSA doesn’t recommend this, but it is available. However, when requesting authorization, the requester does not have any information on what a “unit” is; they simply have to enter the number of units they’re requesting. The county workgroup indicated that it would be helpful to have a label showing what the units are equal to once the Auth Code has been selected.
    • UPDATE 4/11/2025: We are exploring the cost of this with Streamline. [Zendesk ticket # 63601]
  9. Show more information in the Service Requests for Review/Approval widget.
    • Right now this widget shows the Review Status, which can be either “Initial”, “In Progress”, or “Completed”. This doesn’t take into account the Current Status of each authorization, which may indicate that the request is “Awaiting Secondary Review” or that the Request Status is “Re-submitted”. CalMHSA will be working with Streamline to determine what options really need to be shown on the reviewer’s widget.
    • UPDATE 4/11/2025: CalMHSA is exploring options for this, and may re-evaluated based on the 4/8/25 meeting [Zendesk ticket # 74918]
  10. Justification field isn’t updating.
    • The Justification field is the only field a requester can update when a request is sent back to them for more information. Once re-submitted, the Justification field on the Approval tab is not being updated based on what the requester added. CalMHSA is working with Streamline to fix this issue.
    • UPDATE 4/11/2025: Streamline started development in March 2025. No ETA (it’s unclear if all development occurred in March 2025, or if development continued into April 2025). [Zendesk ticket # 63626]
  11. Justification field editable on ALL authorizations when sent back.
    • If the requester submitted more than 1 authorization at a time, when the request is sent back for more information, the requester can update the Justification field for all authorizations requested, rather than just the one where more information was requested.
    • UPDATE 4/11/2025: We are not pursuing this at this time, as this is an infrequent issue.
  12. A reviewer cannot click into the authorization list after generating an auth to view the details
    • Once an authorization has been generated, the reviewer cannot select the auth from the Auth List. This should be selectable to confirm what was authorized, but not be editable.
    • UPDATE 4/11/2025: We are not pursuing this at this time, as this information can be found in the Authorizations (core) screens.
  13. Review status never seems to be “In Progress”.
    • From testing, the Review Status always seems to be either “Initial” or “Completed”. CalMHSA is working with Streamline to determine when “In-Progress” is valid.
    • UPDATE 4/11/2025: CalMHSA is exploring options for this, and may re-evaluated based on the 4/8/25 meeting [Zendesk ticket # 74918]
  14. Need a way for Sys Admins to be able to see all requests that exist.
    • UPDATE 4/11/2025: Streamline is currently working on this. No ETA. The current workaround is to make the Sys Admins supervisors for all users. [Zendesk ticket # 65501]
Additional Updates from 4/8/25 Meeting:
  1. Potential Bug around list page filters clearing all search results.
    • Tulare County’s experience with the service request list page is that they cannot see the entire list of requests they have submitted.  When they go through the widget, the in progress ones come up, but when they open the filters to see everything, then no requests populate. Sacramento and Sonoma confirmed this was happening for them also. Charla was not able to recreate this in Sandbox QA or Sandbox Prod. CalMHSA is recommending that counties submit a Help Desk ticket if this issue persists. Video evidence would be helpful, if it can be recorded without PHI. Tulare has already submitted a ticket.
  2. Request: Make program fields wider to accommodate long program names.
    • CalMHSA likely won’t pursue this immediately, since it’s a “nice to have” for now.
  3. Request: Add a discrete data field to categorize type of authorization (initial, continuation/reauthorization, extension)
    • CalMHSA will explore options around this request. No ETA.
  4. Request: Show very clearly that the request was modified by the reviewer.
    • CalMHSA likely won’t pursue this immediately, since there’s already a way to see the differences between requested and approved via the Authorizations (core) details screen.
  5. Request: Add messaging/Clearer Alerts
    • CalMHSA likely won’t pursue this immediately, since there’s already alerts/messages and widgets to this effect.
  6. Request: Automatically create an initial authorization when a client is enrolled in designated programs
    • CalMHSA likely won’t pursue this immediately, since it’s a “nice to have” for now.
  7. Request: Receiver (program that will be providing the authorized services) needs to be able to see the authorization details
    • CalMHSA will explore options around this request. No ETA.
  8. Request: Requester needs to be able to see the result of their request
    • CalMHSA will explore options around this request. No ETA.
  9. Request: DO NOT deactivate the Authorization Tracking document until other issues are resolved
    • CalMHSA will not deactivate the Authorization Tracking document until counties provide feedback that they’re ready for this document to be deactivated.
  10. Request: When an authorization is generated through Service Request, auto-generate an authorization number
    • CalMHSA likely won’t pursue this immediately, since it’s a “nice to have” for now.
  • Last Updated: April 11, 2025