CurrentCentenePolicy N/A

Prior Authorization (PA) Requirements for CHPIV Medi‑Cal FFS Members

Lists services, procedures, equipment and outpatient pharmaceuticals that require prior authorization or notification for CHPIV Medi‑Cal FFS members and explains submission and timeline requirements for providers.

Policy Summary

PayerCentene

PolicyPrior Authorization (PA) Requirements for CHPIV Medi‑Cal FFS Members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit PA requests via fax, phone, or online with supporting medical records and evidence of conservative treatment to the Health Net contact lines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservice/procedure categories requiring PA or notification

5 business daysroutine PA timeframe

72 hoursurgent PA timeframe

24 hoursemergency hospitalization notification

12 visitsrehab authorization threshold

services exempt from PA

Services Requiring Prior Authorization and Exceptions

PA Criteria and Notations

Specific services, equipment, procedures and outpatient pharmaceuticals require prior authorization (PA) or notification as indicated below. Where noted, authorization vendors or timing/notification instructions apply.

ALL of the following

All elective medical and surgical inpatient hospitalizations require prior authorization (includes acute care, acute/sub-acute rehabilitation, musculoskeletal procedures authorized by Turning Point Healthcare Solutions, LLC).
Emergency hospitalizations require notification within 24 hours of admission; contact the Hospital Notification Fax Line.
Hospitalizations to a nonparticipating hospital after emergency stabilization require authorization as indicated.

ALL of the following

Adult DME items such as BiPAP, power wheelchairs, ventilators may require PA; items with Medi-Cal purchase price greater than $1,500 may require PA.

ALL of the following

Neurostimulators, implantable pain pumps and other implantable devices require authorization and, where specified, are authorized by external vendors such as TurningPoint Healthcare Solutions, LLC.

ALL of the following

Outpatient behavioral health services are authorized by the Behavioral Health Team; PA is not required for in‑network psychotherapy and medication.
Community‑Based Adult Services (CBAS): PA required for >5 visits/week; 1–5 visits/week require notification only (fax authorization/notifications to 833‑581‑5908).

ALL of the following

Some services require authorization from external vendors (e.g., TurningPoint Healthcare Solutions, Evolent Specialty Services, Coram for infusion, Pharmacy Department for drug authorization).
Transplant requests: fax to the Transplant Team as specified in policy.

Prior Authorization Exemptions and Limitations

The following services do not require referral or prior authorization (sensitive services, minor consent services, certain preventive and emergency services, and other exceptions) unless otherwise specified.

Sensitive and minor consent services (no PA required)

Minor consent services including, for minors under age 12 and under 21 as specified: pregnancy and pregnancy-related services; family planning services; sexual assault services.
Infectious, contagious, or communicable disease diagnosis and treatment; sexually transmitted infection prevention, diagnosis and treatment.
Drug and alcohol abuse treatment and counseling.
Outpatient mental health treatment and counseling for minors when the attending professional determines the minor is mature enough to consent per Family Code section 6924.

Limitations and Exclusions Examples

Examples of items noted under limitations, exclusions, and exceptions include:

OB/GYN services from a participating provider and services provided at Indian Health Service facilities are not subject to PA when provided by participating providers.

Biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer (FDA‑approved tests) is exempt from prior authorization.

COVID‑19 diagnostic and screening testing are not subject to prior authorization.

Revocation of hospice election and associated documentation (written initial plan of care, attending physician prescription justifying inpatient level of care, face-to-face encounter documentation, transfer summary when changing health plan carriers) are listed among items that do not require PA; refer to APL 25‑008 for details.

Basic prenatal care with a participating network obstetrician and preventive services from participating providers do not require prior authorization.

Coding, Durable Medical Equipment and Outpatient Pharmaceuticals

Proprietary laboratory analyses (Covered CPT)CPTCovered

0457U	Proprietary laboratory analysis - specific analyte / methodology (see policy)
0459U	Proprietary laboratory analysis - specific analyte / methodology (see policy)
0462U	Proprietary laboratory analysis - specific analyte / methodology (see policy)
0468U	Proprietary laboratory analysis - specific analyte / methodology (see policy)
0472U	Proprietary laboratory analysis - specific analyte / methodology (see policy)

How to Submit Prior Authorizations and Contact Information

Prior Authorization

How to Submit a PA Request

Submit prior authorization (PA) requests by phone, fax, or online. Include pertinent medical records, treatment plans, diagnostic test results, and evidence of prior/conservative therapies to support medical necessity. Submit requests as soon as the need for service is identified to avoid delays. Emergency services do not require prior authorization but must be reported as outlined below.

Submission channels: Phone: 833-236-4141; Fax: 800-743-1655; Online: provider.healthnetcalifornia.com
Required attachments: pertinent medical records, treatment plans, test results, imaging reports, operative reports, and documentation of conservative treatment or step therapy trials when applicable
If the request is for a specialized vendor (e.g., Coram, Evolent), follow vendor-specific submission routes and include vendor-required documentation

Note

PA Submission Timelines

Definitions, Carve-outs and Policy Scope Notes

Medical necessity — inv-16

DefinitionMedical necessity must exist for any plan benefit to be a covered service whether a prior authorization is required or not.

Coverage implicationEven if PA is granted, eligibility rules and benefit limitations still apply to determine coverage

Provider responsibilityProviders must verify member eligibility through the Provider Services Center prior to providing care

PA list — inv-17

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

Member resourcesMembers should consult their Evidence of Coverage (EOC) for full coverage details

Policy Summary

PayerCentene

PolicyPrior Authorization (PA) Requirements for CHPIV Medi‑Cal FFS Members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit PA requests via fax, phone, or online with supporting medical records and evidence of conservative treatment to the Health Net contact lines.

SourceLink

On This Page

Intimate partner violence services.

Adult sensitive care services (no PA required)

Family planning and birth control including sterilization for adults age 21 and older; pregnancy testing and counseling and other pregnancy-related services.
HIV/AIDS prevention and testing; sexually transmitted infections prevention, testing and treatment; sexual assault care; outpatient abortion services.

ALL of the following

Referral or prior authorization is not required for CPSP services; services may be obtained from any participating CPSP provider (see CPSP website for information).

ALL of the following

Basic prenatal care with a participating network obstetrician; preventive services from a participating provider; services for emergency medical conditions (after stabilization subject to review); initial specialist referral (initial referral to participating specialist); urgently needed services when the member is outside their county; certified nurse midwife and OB/GYN services from a participating provider; Indian Health Service facilities; biomarker testing for insured members with advanced/metastatic (stage 3 or 4) cancer (FDA approved); COVID‑19 diagnostic and screening testing; services under the Children and Youth Behavioral Health Initiative fee schedule; initial mental health and substance use disorder assessments; adult preventive immunizations from a participating provider.

ALL of the following

Certain non-emergency medical transportation (NEMT) transfers in specified inpatient transfer scenarios do not require PA as noted; carve-out services such as CCS-eligible conditions require authorization from the local CCS office and must be provided by CCS‑paneled providers/facilities.

Timelines for submitting PA requests depend on urgency and setting. Routine/elective services should be submitted well in advance; urgent requests have shortened timeframes. Emergency hospitalizations require notification within 24 hours of admission.

Elective outpatient or inpatient services: Submit as soon as the need is identified; for scheduled procedures, submit at least 5 business days before the procedure
Urgent requests/procedures: Submit within 72 hours of the scheduled procedure or need
Emergency services: No prior authorization required; notify the plan within 24 hours of admission (or as soon as reasonably possible)

Documentation Required

PA Requirements and Provider Notes

Specific PA requirements and provider notes for outpatient pharmaceuticals and biosimilars: many medical-benefit drugs require PA and are authorized by the Pharmacy Department. Preferred biosimilars must be tried before non-preferred branded products will be approved. Follow age-specific guidance and vendor authorization rules where applicable.

Outpatient pharmaceuticals under the medical benefit require PA when listed; contact the Pharmacy Department for medical-benefit drug authorizations
Biosimilars: preferred biosimilars are required in lieu of branded drugs; prior authorization is required and trial of preferred products is required before non-preferred approval
Examples (not exhaustive): Certain aflibercept, denosumab, eculizumab, corticosteroid ophthalmic injections and other specialty agents require PA; refer to the drug-specific policy for full lists
Authorized infusion provider: Coram is the preferred infusion provider for many medical-benefit drugs; contact Coram at 866-899-1661 (fax: 866-843-3221) for coordination

Note

PA Contact Information

Primary contacts and submission routes for prior authorization, hospital notifications, long-term care admissions, specialty vendors, and other commonly used departments. Providers should use member ID cards for member service numbers when in doubt.

General prior authorization requests: Phone: 833-236-4141; Fax: 800-743-1655; Online: provider.healthnetcalifornia.com
Hospital Notification Unit / Post-stabilization notification: Fax: 800-676-7969; Post-stabilization phone: 800-995-7890 (notify within 24 hours of emergency admission)
Long-Term Care Intake Line: Phone: 800-453-3033; Fax: 855-851-4563
Coram Specialty Infusion Services (preferred home infusion): Phone: 866-899-1661; Fax: 866-843-3221
Evolent Specialty Services (advanced & cardiac imaging): Phone: 855-510-3720; Online submission: www.radmd.com
Behavioral Health Team: 844-966-0298
Eligibility and benefits inquiries: 833-236-4141
Dental (Denti-Cal): 800-322-6384
CCS resources and paneling inquiries: https://www.dhcs.ca.gov/services/ccs/pages/default.aspx and provider enrollment https://www.dhcs.ca.gov/services/ccs/Pages/ProviderEnroll.aspx (916) 552-9105 option 5, then option 2

Provider noteAbsence of an 'X' on this list may indicate PA is not required or the item may not be a covered benefit

Limitations and Exclusions — inv-18

ScopeLimitations and Exclusions list prior authorization limitations, exclusions, and exceptions, including sensitive services that do not require PA.

ExamplesIncludes items such as OB/GYN services from participating providers, biomarker testing (FDA‑approved advanced/metastatic cancer), and COVID‑19 diagnostic/screening testing

Interaction with county programsSome services (e.g., specialty mental health, select substance use disorder services) are covered by county programs and not by Health Net

Carve-out/CCS services — inv-19

CCS (carve‑out) authorizationAuthorization for carve‑out services (e.g., CCS‑eligible conditions) requires prior authorization from the local CCS office.

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

Regulatory referenceServices related to CCS‑eligible conditions must be approved by the CCS program (see California Code of Regulations, Title 22, CCS Medical Eligibility)

Limitations and Exclusions — inv-20

Limitations and Exclusions (short)Prior authorization limitations and exclusions identify services not requiring PA and other coverage exceptions.

Common inclusionsExamples include participating‑provider OB/GYN services, preventive immunizations from participating providers, and certain behavioral health services under specific schedules

Review noteEmergency room services after stabilization may be subject to review and may not be paid

Prior Authorization Contacts — inv-21

Main PA request phonePrior authorization request: 833‑236‑4141

FaxFax: 800‑743‑1655

Online submission & vendor linesprovider.healthnetcalifornia.com; specialized vendor contacts listed (e.g., Evolent 855‑510‑3720, Coram Specialty Infusion 866‑899‑1661)