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Prior Authorization (PA) requirements for CalViva Health Medi‑Cal FFS

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Lists services, procedures, equipment, timelines, submission instructions, and prior authorization requirements that govern PA for CalViva Health Medi‑Cal fee‑for‑service members in Fresno, Kings, and Madera counties; affects providers submitting PA requests for those members.

Policy Summary

PayerCentene (CalViva Health via Health Net)

PolicyPrior Authorization (PA) requirements for CalViva Health Medi‑Cal FFS

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via fax, phone, or online and attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3counties governed

As identified; ≥7d; 72hPA timelines

> $1,500DME threshold

Require PAGene therapies

~15PA contact lines

Services and Coverage Rules Requiring Prior Authorization

Example PA coverage criteria

Selected examples of services and whether PA is required (X indicates PA required; notification-only or specific authorizers noted where applicable).

All elective medical and surgical inpatient hospitalizations: PA required for adult and pediatric members.

All emergency hospitalizations within 24 hours of hospital admission: notification required (adults); see inpatient table for PA indicators for pediatric and adult members.

Skilled nursing facility admissions (all elective admissions): PA required for adult and pediatric members.

Diagnostic advanced imaging (CT/MRI/PET) and cardiac imaging (CCTA, MPI): PA required; authorized by Evolent Specialty Services, Inc.

Durable medical equipment (DME) including BiPAP, hospital beds, oxygen, power wheelchairs: PA required for adults and pediatrics; PA required for Medi-Cal purchase price > $1,500 and for all pediatric DME.

Radiation therapy: All pediatric radiation therapy requires PA; certain adult radiation modalities may require PA.

Medications and outpatient pharmaceuticals submitted under the medical benefit: May require PA; self-injectables are under Medi-Cal Rx (use Contract Drug List) and some office-administered self-injectables require PA from Pharmacy Services.

Gene therapy (including CAR-T therapies): PA required for adult and pediatric members; note carve-out of certain sickle cell gene therapies to Medi-Cal FFS effective 7/1/2025.

Out-of-network providers and services: Services rendered by out-of-network providers require PA (excludes certain emergency/self-referral services allowed under Medi-Cal).

Reconstructive and cosmetic surgery: Cosmetic surgery is not a Medi-Cal benefit; requests are reviewed for possible reconstructive benefits and medical necessity — PA required where indicated.

Pharmaceutical coverage stance

Outpatient pharmaceuticals submitted under the medical benefit are listed; biosimilars are preferred and require prior authorization.

Extensive enumerated list of outpatient pharmaceuticals submitted under the medical benefit (see provider list).

Biosimilars are required in lieu of branded drugs and require prior authorization; preferred biosimilars must be tried prior to non-preferred approval and are authorized by Pharmacy Services.

For the reference product, all generics or biosimilar drugs will require a prior authorization where applicable; contact Pharmacy Services for authorization details.

Authorization exceptions and limitations

Prior authorization requirements and exceptions for non-benefit community supports, carve-outs (CCS), and sensitive services.

Non-benefit community supports (Community Supports) such as assisted living facility transitions; environmental accessibility adaptations (home modifications); housing deposits; housing tenancy and sustaining services; housing transition navigation services; meals/medically tailored meals; personal care and homemaker services; recuperative care (medical respite); respite services; short-term post-hospitalization housing; transitional rent; day habilitation; asthma remediation; and similar services require prior authorization and refer to CalAIM Resources for Providers.

Authorization for carve-out services not covered by Health Net/CalViva (for example, CCS-eligible conditions) must be obtained from the local CCS office; CCS services must be provided by CCS-paneled providers at CCS-approved facilities and any CCS-related services must be approved by the CCS program.

Exceptions (sensitive/minor consent services)

Minor consent services including pregnancy and pregnancy-related services, family planning, and sexual assault services (for children under 12 and ages 12 to under 21).
For ages 12 and older under 21: infectious disease diagnosis and treatment, sexually transmitted disease prevention/diagnosis/treatment, drug and alcohol abuse treatment and counseling, outpatient mental health treatment and counseling (when minor deemed mature per Family Code section 6924).

Certain sensitive services such as outpatient abortion services and CPSP services do not require referral or prior authorization as listed in the policy.

Limitations and Prior Authorization Exceptions by Age

Limitations, exclusions, and prior authorization exceptions are indicated for Adult Members (ages 21 and over) and Pediatric Members (under age 21).

Ages 21 and Over: Multiple services are marked with PA/limitation indicators for adult members, including initial mental health and substance use disorder assessments, adult preventive immunizations (when provided by participating providers), and second opinions where noted; refer to the table for specific X indicators.

Under Age 21: Multiple services are marked with PA/limitation indicators for pediatric members, including initial mental health and substance use disorder assessments, pediatric preventive immunizations, and second opinions where noted; all pediatric radiation therapy requires PA.

Services rendered under the Children and Youth Behavioral Health Initiative are billed under a specific fee schedule and may be subject to separate rules and review processes.

Codes and Pricing Thresholds

Proprietary laboratory analyses (Covered CPT)CPTCovered

0457U	Proprietary laboratory analysis - specific assay
0459U	Proprietary laboratory analysis - specific assay
0462U	Proprietary laboratory analysis - specific assay
0468U	Proprietary laboratory analysis - specific assay
0472U	Proprietary laboratory analysis - specific assay
0577U	Proprietary laboratory analysis - specific assay
0579U	Proprietary laboratory analysis - specific assay
0591U	Proprietary laboratory analysis - specific assay
0596U	Proprietary laboratory analysis - specific assay
0598U	Proprietary laboratory analysis - specific assay

1–10 of 11

1/2

Outpatient Pharmaceuticals (Medical Benefit) - Listed DrugsmixedCovered

See list

Extensive list of outpatient pharmaceuticals submitted under the medical benefit (see policy drug lists).

Outpatient procedures and specialty agentsmixedCovered

See policy

Multiple procedure and specialty agent classes listed under outpatient procedures section (e.g., gene therapies, CAR-T, immunoglobulin, oncology agents, biologics). Refer to specific drug/class entries for PA and age-based rules.

inv-08: DME purchase price threshold — Medi-Cal purchase price > $1,500 requires PA (and pediatric DME rules)

DME purchase price thresholdMedi-Cal purchase price greater than $1,500 requires prior authorization. All DME for pediatric members requires prior authorization.

How to Submit Prior Authorizations and Contact Points

Prior Authorization

Prior Authorization Request

Submit a prior authorization (PA) request via phone, fax, or the provider portal. Include pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support medical necessity. For online submissions, use provider.healthnetcalifornia.com. For additional guidance to avoid processing delays, follow the submission checklist in Avoid Processing Delays for Prior Authorization Requests with These Guidelines.

Phone: 888-893-1569
Fax: 800-743-1655
Online: provider.healthnetcalifornia.com

Note

Medi‑Cal Member Services

Medi‑Cal members and providers may contact Medi‑Cal Member Services for eligibility, benefit coordination, and assistance with specialty mental health/county referrals. Member Services can also help with coordination when county mental health or substance use services are involved.

Medi‑Cal Member Services: 888-893-1569
Medi‑Cal general information: www.medi-cal.ca.gov

Prior Authorization

Long‑term Care Intake

Long‑term care admissions, notifications and related authorization requests must be routed through the Long‑term Care Intake Line. Use this line for skilled nursing facility (SNF) and other long‑term care authorizations and notifications.

Phone: 800-453-3033
Fax: 855-851-4563

Prior Authorization

Transplant Prior Authorization / Contact

Transplant services require prior authorization and coordination with the Transplant Team. Submit transplant authorization requests and related documentation by fax to the Transplant Team.

Transplant Team fax: 833-769-1141

Scope, Definitions, and Policy Notes

Medical necessity — definition

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

ApplicabilityThis requirement applies regardless of whether prior authorization is listed as required for the service

Provider responsibilityProviders must verify that services meet medical necessity and benefit limitations even if PA is authorized

PA list scope (coverage vs. PA requirement)

Scope of PA listThis PA list contains services that require prior authorization only and is not a comprehensive list of covered services.

Authoritative coverage sourceThe member's Evidence of Coverage (EOC) provides the complete list of covered services; EOCs available at bit.ly/CVH-EOC

Verification requirementProviders are responsible for verifying member eligibility and benefit limitations prior to providing care

Gene therapy (includes CAR‑T) — definition and notes

DefinitionGene therapy includes CAR‑T therapies and other gene-modifying products; examples listed include Abecma, Breyanzi, Yescarta, Zolgensma, Kymriah, Tecartus, Roctavian, Luxturna, Hemgenix, and others.

CAR‑T examplesExamples marked as CAR‑T include Abecma®, Breyanzi®, Yescarta™, Tecartus™, Kymriah™

Carve-out noteEffective 7/1/2025, gene therapies for sickle cell disease (including Casgevy™ and Lyfgenia™) are carved out to Medi‑Cal FFS through DHCS

PA requirementGene therapy (including CAR‑T) is indicated as requiring prior authorization (X)

Biosimilar requirement and PA

Biosimilar substitution policyBiosimilars are required in lieu of branded drugs; preferred biosimilars must be used prior to non-preferred approval.

Prior authorization for biosimilarsBiosimilars require prior authorization and are authorized by Pharmacy Services.

Step requirementMust try preferred products prior to non-preferred approval; refer to drug-specific policy for preferred product lists.

Exceptions/notesCertain agents list PA exceptions by indication or provider type (e.g., bevacizumab agents—no PA required for ophthalmologists).

Prior Authorization Exceptions — summary

Non-benefit community supportsCertain non-benefit community supports (e.g., assisted living facility transitions, environmental accessibility adaptations, housing deposits, meals, respite, recuperative care, day habilitation) require prior authorization and reference CalAIM resources.

Carve-out authorizationsAuthorization for carve‑out services not covered by Health Net/CalViva (e.g., CCS‑eligible conditions) must be obtained from the local CCS office and provided by CCS‑paneled providers at CCS‑approved facilities.

Sensitive services exceptionReferral or prior authorization is NOT required for specified sensitive/minor consent services (pregnancy-related, family planning, sexual assault, infectious disease treatment, STD services, drug and alcohol counseling, outpatient mental health for minors meeting statutory criteria) and CPSP services.

Children and Youth Behavioral Health Initiative — billing note

CYBHI billing noteServices rendered under the Children and Youth Behavioral Health Initiative fee schedule are billed under that specific fee schedule and may be subject to separate rules.

ContextCYBHI services are identified within the limitations and exceptions section, distinct from standard PA indicators.

Provider actionProviders should bill CYBHI services under the initiative's fee schedule and follow any separate authorization or documentation requirements noted there.

Policy Summary

PayerCentene (CalViva Health via Health Net)

PolicyPrior Authorization (PA) requirements for CalViva Health Medi‑Cal FFS

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via fax, phone, or online and attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment.

SourceLink

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