CurrentCentenePolicy N/A

Prior authorization requirements for CalViva Health Medi‑Cal FFS members in Fresno, Kings and Madera counties

List of services, procedures, equipment and outpatient pharmaceuticals that require prior authorization (PA) or notification for CalViva Health Medi‑Cal fee‑for‑service members in Fresno, Kings and Madera counties; intended for providers to verify PA requirements and submission instructions.

Policy Summary

PayerCentene

PolicyPrior authorization requirements for CalViva Health Medi‑Cal FFS members in Fresno, Kings and Madera counties

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit PA requests via fax, phone or online to Health Net and include medical records, treatment plans, test results, and evidence of conservative treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Fresno/Kings/MaderaApplies to counties

DefinedPA timelines

MultiplePharmacy categories enumerated

NumerousPA exceptions

~100+Outpatient pharmaceuticals listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services and Coverage Criteria Requiring Prior Authorization

PA criteria by service category

Covered services and categories requiring prior authorization (PA) or notification. Age-specific indicators (Adult = ages 21+; Pediatric = under 21) are shown where specified. Some authorizations are delegated to specialty vendors as noted.

Inpatient services

All elective medical and surgical inpatient hospitalizations (includes acute care and acute/sub‑acute rehabilitation)
Skilled nursing facility admissions (all elective admissions) — PA required
Emergency hospitalizations — notification required within 24 hours (Hospital Notification Fax Line)

Outpatient advanced diagnostics and imaging

Advanced imaging (CT/CTA, MRI/MRA, PET) and cardiac imaging (CCTA, MPI) — PA required; requests authorized by Evolent Specialty Services

Surgery and procedural categories

Spinal surgery (e.g., laminotomy, diskectomy, vertebroplasty, nucleoplasty, X‑Stop) — PA required; adults authorized by TurningPoint, pediatrics authorized by Health Net
Joint surgeries (ankle, hip, knee, shoulder) — PA required; adult members authorized by TurningPoint
All outpatient elective surgery for pediatric members — PA required

Durable medical equipment and supplies

High‑cost DME (oxygen, power wheelchairs, scooters, ventilators) — PA required
Incontinence supplies beyond 186 units per calendar month or beyond the $165 Medi‑Cal purchase price — PA required (see limits)
Custom orthotics — PA required for adults; pediatric custom orthotics require PA

Rehabilitation and therapy services

Physical, occupational and speech therapy — authorization required after 12 combined visits for adults; pediatric members require PA
Wound care (skin substitutes and biologics) — PA required; debridement authorization after 12 sessions/year

Medications and outpatient pharmaceuticals (medical benefit)

Medications newly approved by FDA — PA may be required; contact Pharmacy Services
Self‑injectables administered in physician office — PA required from Pharmacy Services (self‑injectables otherwise managed by Medi‑Cal Rx)
Multiple high‑cost classes (gene therapies including CAR‑T, exon‑skipping therapies, immune globulins, PD‑1/PD‑L1 inhibitors, PAH agents, lysosomal storage disorder therapies, etc.) — PA required (age‑specific X applies)

Specialty/contracted vendor authorizations

Musculoskeletal procedures and certain adult musculoskeletal authorizations handled by TurningPoint Healthcare Solutions (TurningPoint contact applies)
Advanced and cardiac imaging requests authorized by Evolent Specialty Services
Infusion therapy preference: Coram is preferred infusion provider; Pharmacy Services handles authorization for drug/therapy classes

Other specified services

Out‑of‑network provider services — PA required (except emergencies and certain self‑referral services)
Proprietary laboratory analyses — PA required
Non‑emergency medical transportation (NEMT) — PA required with Physician Certification Statement; contact Care Ride/Modivcare
Dental anesthesia (IV moderate/deep/general) — PA required

Coverage stance for outpatient pharmaceuticals and PA exceptions

Outpatient pharmaceuticals submitted under the medical benefit generally require prior authorization. Specific drug classes and examples are enumerated below. Biosimilars are required where indicated and require PA.

Drug list (examples): Extensive outpatient pharmaceutical list requiring PA when submitted under the medical benefit (select examples include Abrilada, Adakveo, Adcetris, Amvuttra, Botox, Darzalex, Eylea/aflibercept agents, H.P. Acthar Gel, Ilaris, Kimmtrak, Leqembi, Myozyme, Ocrevus, Spinraza, Tecartus, Yescarta and many others). See full list for all products.

Class‑level rules and examples

Gene therapies (including CAR‑T) and exon‑skipping therapies — PA required for listed products (age‑specific indicators apply)
Immune globulin agents, PD‑1/PD‑L1 inhibitors, PAH agents, lysosomal storage disorder therapies, natalizumab, omalizumab, ranibizumab, and others — PA required (examples provided)

Self‑injectables and administration notes:

Prior Authorization Exceptions

The following services and service categories do not require prior authorization per this policy.

COVID‑19 diagnostic and screening testing

Initial mental health and substance use disorder assessments

Adult preventive immunizations from a participating provider

Second opinions from a participating physician or other provider

Lactation consultation services for pregnant and postpartum members

Non‑hospital‑grade (manual and electric) breast pumps (age‑specified: pediatric under 21 requires X for availability noted) — no PA

Submission Channels and Contacts

Prior authorization and notification requests may be submitted via the channels and contacts listed below. Use the vendor/department contact appropriate to the service type.

General and hospital notifications

Prior authorization requests: phone 888‑893‑1569; fax 800‑743‑1655; online: provider.healthnetcalifornia.com
Hospital Notification Unit fax: 800‑676‑7969; Post‑stabilization Notification phone: 800‑995‑7890
Long‑term Care Intake Line: 800‑453‑3033; fax: 855‑851‑4563

Specialty vendor and program contacts

Evolent Specialty Services (advanced and cardiac imaging): 800‑424‑4809; online submission via radmd.com

Codes, Coding Rules, and Quantity Limits

inv-09: Incontinence supplies limit — quantity/price threshold (186 units per month or $165 Medi-Cal purchase price).

Incontinence Supplies Limit

inv-10: Wound debridement authorization threshold — authorization required after 12 sessions per year.

Wound Debridement Authorization Threshold

Provider Submission Instructions and Operational Requirements

Prior Authorization

Submission instructions

Submit prior authorization (PA) requests via fax, phone or online. Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support medical appropriateness. For hospice inpatient PA and other specialty PAs, include the required documentation listed below. For general submission guidance, see the Health Net submission guide.

Fax, phone, or online submission accepted
Include medical records, treatment plans, test results, conservative treatment evidence
See Health Net submission guide for tips to avoid delays

Note

PA timing and urgency

Timelines vary by setting and urgency. Elective inpatient or outpatient services: submit as soon as need is identified. Routine requests: submit at least 7 calendar days (or 5 business days, whichever comes first) before scheduled procedure. Urgent requests: submit at least 72 hours before procedure. Emergency services do not require prior authorization. Inpatient notification and post-stabilization hospital notifications have separate timing rules (see Hospital Notification Unit).

Definitions, Scope, and Policy Notes

Medical necessity definition

Core definitionMedical necessity must exist for any plan benefit to be a covered service whether a PA is required or not.

Coverage implicationEven if a service appears on the PA list, eligibility rules and benefit limitations still apply

Reference for disputesMember's Evidence of Coverage (EOC) provides the definitive list of covered services

PA list scope

Scope clarificationThis PA list identifies services that require prior authorization only and is not a list of covered services.

Provider responsibilityProviders must consult the member's Evidence of Coverage (EOC) to determine covered benefits

Policy Summary

PayerCentene

PolicyPrior authorization requirements for CalViva Health Medi‑Cal FFS members in Fresno, Kings and Madera counties

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit PA requests via fax, phone or online to Health Net and include medical records, treatment plans, test results, and evidence of conservative treatment.

SourceLink

On This Page

Self‑injectable medications are managed by the Medi‑Cal Rx program; PA may be required. PA is required from Pharmacy Services for self‑injectables administered in a physician's office (use Cover My Meds or fax form to 800‑859‑4325).

Biosimilar policy: Biosimilars require prior authorization; preferred biosimilars are required in lieu of branded drugs and preferred products must be tried prior to non‑preferred approval. Specific substitution and preferred product notes provided in policy.

Exceptions and carve‑outs

Carve‑out services (e.g., CCS) require authorization from local CCS office and CCS‑approved providers/facilities
Enumerated non‑PA services (see Prior Authorization Exceptions section) such as certain preventive immunizations, initial mental health/substance use disorder assessments, COVID‑19 testing, certain CPSP services, etc.

Basic prenatal, maternal and preventive services per current ACOG/CPSP clinical standards — no PA

California Prenatal Screening (PNS) Program services — no PA

Services for emergency medical conditions and post‑stabilization — no PA (notification rules apply for hospital admissions)

Initial specialist referral to a participating specialist — no PA

Urgently needed services when the member is outside their county — no PA

Certified nurse midwife and OB/GYN services from a participating provider — no PA

Biomarker testing for insured members with advanced/metastatic stage 3 or 4 cancer (FDA‑approved) — no PA

Services rendered under the Children and Youth Behavioral Health Initiative fee schedule — no PA

Non‑emergency transfers that meet specified conditions (see policy) and certain NEMT provisions — see policy exceptions

Outpatient hospice routine home care, continuous home care, respite care, and hospice physician services do not require PA (inpatient hospice care does require PA)

Sensitive services and minor consent services (per policy list) — no PA

TurningPoint Healthcare Solutions (musculoskeletal requests): 855‑332‑5898; fax 949‑774‑2254; www.myturningpoint‑healthcare.com; email centenecaum@turningpoint‑healthcare.com

Coram Specialty Infusion Services (preferred infusion): 866‑899‑1661; fax 866‑843‑3221

Pharmacy and transportation contacts

Pharmacy Services: 800‑867‑6564, option 2; fax: 833‑953‑3436 (also submit PA/forms for medical benefit drugs)
Care Ride Unit (NEMT prior authorization) fax: 833‑701‑0051; Modivcare scheduling: 866‑529‑2128; fax: 877‑457‑3352
Public Programs (for CBAS) face‑to‑face authorization/notification fax: 833‑581‑5908

Other support contacts

Medi‑Cal general information: medi‑cal.ca.gov; Member Services: 888‑893‑1569; Eligibility and benefits: 888‑893‑1569
Nurse Advice Line (24/7): 800‑675‑6110; Provider Services Center: 888‑893‑1569
Transplant Team fax: 833‑769‑1141; CCS information and paneling inquiries: dhcs.ca.gov/services/ccs (paneling phone listed in policy)

Elective services: submit as soon as need identified
Routine: ≥7 calendar days (or 5 business days) before procedure
Urgent: ≥72 hours before procedure
Emergency services: no PA required

Prior Authorization

Inpatient notification / prior authorization

Inpatient and emergency hospitalization rules: notify Health Net for emergency hospitalizations within 24 hours of admission (notification only for emergency admissions). Elective inpatient admissions require prior authorization. For admissions to nonparticipating hospitals once emergency stabilization is complete, authorization requirements apply. Long-term care nursing facility admissions should be routed to the Long‑Term Care Intake Line. Contact the Hospital Notification Unit or Post‑stabilization Notification lines as listed in the PA Contacts.

Elective inpatient medical and surgical hospitalizations: prior authorization required
Emergency hospitalizations: notification required within 24 hours (contact Hospital Notification Fax Line)
Admissions to nonparticipating hospitals post-stabilization: authorization rules apply
Long-term care nursing facility admissions: contact Long‑Term Care Intake Line

Prior Authorization

Hospice prior authorization rules

Hospice prior authorization rules: Inpatient hospice care requires prior authorization through standard PA processes. Attach required documentation and submit to Health Net Prior Authorization. Outpatient hospice services (routine home care, continuous home care, respite care) and hospice physician services do not require prior authorization; submit required documentation via encrypted email to HospiceCTIforms@centene.com. Required documentation includes certification of the patient's terminal illness and the Medi‑Cal Hospice Program Election form.

Inpatient hospice care: prior authorization required; attach required documentation
Outpatient hospice services and hospice physician services: PA not required for routine home care, continuous home care, and respite; submit documentation via encrypted email to HospiceCTIforms@centene.com
Required documentation: certification of terminal illness; Medi‑Cal Hospice Program Election form

Note

Carve-out / CCS authorization

Carve-out services (for example, California Children’s Services [CCS] eligible conditions and local educational agency [LEA] services) require authorization from the responsible program or local office. CCS services must be authorized by the local CCS office, provided by CCS‑paneled providers, and performed at CCS‑approved facilities. Authorizations for LEA carve‑out services (speech, occupational therapy, audiology for children ≥3, psychological testing for ADD/ADHD, etc.) are referred to the local school district.

CCS-eligible conditions: prior authorization must come from local CCS office; use county CCS contact list
CCS services must be delivered by CCS-paneled providers at CCS-approved facilities
LEA carve-out services (speech/OT/audiology for children ≥3, school-based psychological testing): refer to local school district for authorization

Note

Prior authorization exceptions and limitations

Prior authorization exceptions and limitations — do not require PA: sensitive and minor-consent services (family planning, pregnancy-related services, sexual assault services; infectious disease testing/treatment; STD services; drug and alcohol treatment; certain outpatient mental health services for minors), outpatient abortion services, Comprehensive Perinatal Services Program (CPSP) services, basic prenatal/maternal/preventive services per ACOG/CPSP, California Prenatal Screening, emergency medical conditions, initial specialist referrals, urgently needed services when member is outside county, participating CNM and OB/GYN services, MOA 638 IHS facilities, biomarker testing for advanced/metastatic cancer (FDA‑approved), COVID‑19 diagnostic and screening testing, services under Children and Youth Behavioral Health Initiative fee schedule, initial mental health and SUD assessments, adult preventive immunizations from participating providers, second opinions, lactation consultations, and non‑hospital‑grade breast pumps. Certain NEMT transfers (e.g., ER to inpatient or acute hospital to SNF/ICF/post‑acute psychiatric facilities) do not require PA. Routine labs and radiology must be performed at participating facilities.

Sensitive/minor consent services and listed public‑health services: no PA required
Comprehensive Perinatal Services Program (CPSP) services: no PA required
Emergency medical conditions and urgently needed services outside county: no PA required
Initial mental health and SUD assessments: no PA required
COVID‑19 diagnostic and screening testing: no PA required
Certain NEMT transfers between inpatient/acute/post‑acute settings: no PA required
Routine lab and radiology: must be performed at participating facilities

Note

Prior authorization contact information

Use the contacts below to submit prior authorization requests, notify for hospital admissions, request specialty authorizations, or get help with member eligibility and benefits. If in doubt, refer members to the number on their ID card.

Prior authorization requests: 888‑893‑1569; fax: 800‑743‑1655; provider.healthnetcalifornia.com
Hospital Notification Unit fax: 800‑676‑7969; Post‑stabilization Notification: 800‑995‑7890
Long‑Term Care Intake Line: 800‑453‑3033; fax: 855‑851‑4563
Care Ride Unit (NEMT prior authorization): fax 833‑701‑0051; Modivcare scheduling (NEMT/NMT): 866‑529‑2128; fax 877‑457‑3352
Transplant Team fax: 833‑769‑1141; TurningPoint (musculoskeletal): 855‑332‑5898; fax 949‑774‑2254; Evolent (advanced/cardiac imaging): 800‑424‑4809; online: www.radmd.com
CCS information and county contacts: www.dhcs.ca.gov/services/ccs/pages/default.aspx; CCS paneling inquiries: www.dhcs.ca.gov/services/ccs/Pages/ProviderEnroll.aspx, 916‑552‑9105 (select option 5, then option 2)
Pharmacy Services: 800‑867‑6564, option 2; fax: 833‑953‑3436
Behavioral Health Team: 844‑966‑0298
Provider Services / Eligibility & Benefits / Medi‑Cal Member Services: 888‑893‑1569
Care Ride Unit (ambulance, stretcher, wheelchair, door‑to‑door assistance) is responsible for ground NEMT authorization; air ambulance is authorized by Health Net on behalf of CalViva Health

PA guaranteePA is guaranteed only at the time of access to this list; verification of eligibility is required prior to care

Biosimilars requirement

Biosimilar substitution ruleBiosimilars are required in lieu of branded drugs and require prior authorization; preferred biosimilars must be tried prior to approval of non-preferred products.

Authorization authorityBiosimilar approvals are managed by Pharmacy Services

Product-specific guidanceRefer to the drug-specific policy for the complete list of preferred biosimilar products and exceptions (e.g., certain oncology indications noted)

CCS carve-out

CCS carve-out requirementAuthorization for CCS-eligible services must be obtained from the local California Children's Services (CCS) office, not through the managed plan.

Provider and facility requirementCCS services must be provided by CCS‑paneled providers at CCS‑approved facilities

Regulatory referenceServices related to CCS-eligible medical conditions must be approved by the CCS program per California Code of Regulations (Title 22) guidance

Prior Authorization Exceptions

No-PA: COVID-19 testingCOVID-19 diagnostic and screening testing do not require prior authorization under this plan.

No-PA: Initial behavioral health assessmentsInitial mental health and substance use disorder assessments do not require prior authorization.

No-PA: Preventive and prenatal servicesAdult preventive immunizations and basic prenatal/maternal/preventive services per ACOG/CPSP do not require prior authorization.

No-PA: Emergency and initial specialist referralServices for emergency medical conditions and an initial referral to a participating specialist do not require prior authorization.

Prior Authorization Contacts (definitions)

Primary PA request contactPhone: 888-893-1569; Fax: 800-743-1655; Online: provider.healthnetcalifornia.com

Hospital notificationHospital Notification Unit fax: 800-676-7969; Post-stabilization notification: 800-995-7890

CCS and specialty vendorsCCS contact info: www.dhcs.ca.gov/services/ccs/pages/default.aspx; Evolent for advanced imaging: 800-424-4809; TurningPoint for musculoskeletal requests: 855-332-5898

Pharmacy and NEMT contactsPharmacy Services: 800-867-6564 (opt 2), fax: 833-953-3436; Modivcare NEMT scheduling: 866-529-2128, fax: 877-457-3352