Direct referral
A member may be referred to another contracted RCHN practitioner for certain services without prior authorization from RCHN. Please refer to the RCHN Quick Reference Guide to access the list of services that do not require a prior authorization from RCHN.
Prior authorization
Services that require prior approval by RCHN before those services are rendered.
If approved, the authorization stays active for a specified date range and may expire. For extension requests, complicated cases, or any questions, contact RCHN at 1-877-276-4543.
Services requiring prior authorization
For the most up-to-date information, download the RCHN Quick Reference Guide.
How to Submit Prior Authorizations
Electronic Submission
- Go to https://eznet.rchsd.org/
- Sign in to your EZ-NET account and under the Auth/Referrals tab, click Authorization Submission
- Fill out each section, attach relevant medical records, and a signed order and submit.
Fax Submission
- Download and print RCHN Prior Authorization Form. Fax the completed form to (858)-309-7977.
Authorization Processing Time
- Urgent Authorizations: within 72 hours
- Routine Authorizations: within 7 calendar days (Medi-Cal) / 5 business days (Commercial)
- Retro-Authorizations: within 30 calendar days
- Delay/Extension*: 21 calendar days (Medi-Cal) / 45 calendar days (Commercial)
*When additional clinical information is needed, requests can be extended to allow time for submission of sufficient medical justification for the request
Utilization Management Appeals
Providers may request reconsideration of an Authorization denial by submitting a formal appeal to RCHN either by faxing new information to (858)-309-7977 or by calling to request a Peer-to-Peer Review (see below). Contact RCHN Utilization Management at 877-276-4543 for more information.
Peer-to-Peer Review
Physicians may contact an RCHN physician reviewer to discuss adverse determinations. The name of the reviewing physician and contact information is included in the authorization denial or may be obtained by contacting RCHN Utilization Management at 877-276-4543.
Second Opinions
A member or the member’s authorized representative may request a second medical opinion with an out-of-network provider by contacting the member’s health plan directly. RCHN is not responsible for processing out-of-network second opinions.
If the member wants a second opinion with a provider who is in-network with RCHN then normal authorization guidelines apply, please see the Quick Reference Guide regarding services that require an authorization.