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Provider Bulletin 05-29-2025 Rheumatology Referrals SD
Molina Healthcare·CA · Pediatrics, Rheumatology, Family Medicine·Provider Bulletin
Effective date
May 29, 2025
We identified it
Jun 19, 2026
Summary
Molina Healthcare of California (San Diego) issued new guidelines for pediatric rheumatology referrals effective immediately, requiring prior authorization at time of referral and specific laboratory workup including CBC, CRP, ESR, metabolic panel, urinalysis, and joint X-rays. Referrals without proper clinical history or based solely on positive ANA results may be denied or redirected to alternative care.
Action Required
Immediately: Billing team must ensure all pediatric rheumatology referrals to Rady Children's Hospital include prior authorization requests submitted at time of referral. Providers must complete required lab workup (CBC with differential, CRP, ESR, comprehensive metabolic panel, urinalysis, plain radiographs of affected joints) before submitting referrals. Update encounter forms and EMR templates to include rheumatology referral checklist. Train clinic staff on proper referral and authorization process to avoid treatment delays and potential claim denials.