Attention Providers: Prepare for the Adjudication Response

Attention Providers: Prepare for the Adjudication Response

Adjudication Response
The Department of Health Care Services (DHCS) will soon discontinue the practice of returning adjudicated paper Treatment Authorization Request (TAR) copies to providers. Instead, providers will receive a new document, an Adjudication Response (AR). It is important that providers retain a copy of the submitted paper TAR for future reference.

The AR will display:

• The status of requested service(s)
• The reason(s) for the decision(s), including TAR decisions resulting from an approved or modified appeal
• The adjudicator's request for additional information, if necessary
• The pricing indicator (PI), which will be used as the 11th digit of the TAR Control Number (TCN) for claims

Providers should keep a copy of the AR for resubmitting a deferred paper TAR, or when requesting an update or correction to a previously approved, or modified paper TAR.

Combine Pricing Indicator & TAR Control Number
The last column on the AR will contain the PI number. When submitting claims, the PI number should be included as the last digit (11th) of the TCN. Failing to use the PI when billing will cause the claim to be denied.

When requesting an update or correction, a copy of the AR must be placed on top of the newly submitted documents to ensure accuracy. Providers should clearly specify what change(s) to the AR are being requested.

Faxed Pharmacy AR
An AR for a pharmacy TAR will be faxed to the fax number provided on the TAR for both paper and electronic Treatment Authorization Requests (eTARs). If an AR is not desired for an eTAR, leave the fax number field on the application blank. It is critical that the provider number and fax number fields be completed legibly. If the paper TAR was originally mailed without a fax number, the AR will be mailed to the provider's address on file with the Provider Enrollment Division (PED). Providers should ensure that PED has their most up-to-date mailing address on file. Instructions about updating a provider address may be found on the Provider Enrollment page.

Adjudication Response Example