CurrentCentenePolicy N/A
Prior Authorization Requirements for CHPIV Medi‑Cal FFS Members
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Defines prior authorization (PA) requirements, submission processes, timelines, and services subject to PA for Community Health Plan of Imperial Valley (CHPIV) Medi‑Cal fee‑for‑service members; affects providers serving CHPIV Medi‑Cal enrollees in Imperial County.
Policy Summary
PayerCentene (Health Net / CHPIV)
PolicyPrior Authorization Requirements for CHPIV Medi‑Cal FFS Members
Policy CodePolicy N/A
Change TypeAdministrative (no material clinical changes)
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionSubmit PA requests via fax, phone, or online to Health Net and attach medical records, treatment plans, test results, and evidence of conservative treatment.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
2026-01-01policy effective date
Many servicesPA required (X)
72 hurgent PA timeframe
7 daysroutine PA timeframe
Requiredinpatient hospice PA
~100+outpatient pharma list
Services Requiring Prior Authorization and Coverage Limits
PA Designations by Service Category
Selected service categories and PA designations (X = PA required; notes indicate authorization entity or special instructions).
Inpatient hospitalizations (elective): Prior authorization required (X). Includes acute care and acute/sub‑acute rehabilitation; emergency admissions require notification within 24 hours.
Skilled nursing facility admissions (elective): Prior authorization required (X).
Diagnostic advanced imaging and cardiac imaging: Prior authorization required; authorized by Evolent Specialty Services; includes CT/CTA, MRI/MRA, PET, CCTA, MPI, MUGA.
Durable medical equipment (DME): Prior authorization required for many items; Medi‑Cal purchase price > $1,500 requires PA; examples include BiPAP, hospital beds, power wheelchairs, ventilators.
Outpatient infusion therapy: Prior authorization required (X). Includes blood transfusions and chemotherapy.
Radiation therapy: Prior authorization required for pediatric members (all pediatric radiation therapy requires PA); certain adult modalities limited (IMRT, proton, SBRT, stereotactic radiosurgery).
Transplant evaluations and procedures: Prior authorization required (fax request to Transplant Team); includes evaluations, donor search, transplant procedure.
Medications (medical benefit): Prior authorization required (X) for many outpatient pharmaceuticals; newly FDA‑approved medications may require PA; self‑injectables are managed by Medi‑Cal Rx but PA may be required when administered in a physician's office (PA required from Pharmacy Services).
Rehabilitation services: Prior authorization required after 12 combined visits for physical, occupational and speech therapy (includes home setting).
Outpatient pharmaceuticals coverage with PA expectations
Lists outpatient pharmaceuticals submitted under the medical benefit, examples of agents by class, preferred products, and PA expectations.
Outpatient pharmaceutical agents and classes submitted under the medical benefit require prior authorization (X) as listed. Examples of agent classes with example products: aflibercept (Eylea and biosimilars), alpha‑1 proteinase inhibitors (Aralast NP, Glassia, Prolastin‑C, Zemaira), bortezomib (Velcade), corticosteroid ophthalmic injections (Dextenza, Iluvien, Ozurdex, Yutiq), denosumab (Prolia, Xgeva), eculizumab (Soliris), exon‑skipping therapies (Exondys‑51, Amondys‑45, Viltepso, Vyondys‑53), gene therapies/CAR‑T (multiple named products), GnRH agonists (Lupron Depot, others — note: Camcevi no PA for urology/hematology/oncology), HAE agents, immune globulins (IVIG examples; Preferred: Gammagard, Gamunex‑C), IV iron (Injectafer, Monoferric), lysosomal storage disorder therapies, natalizumab, omalizumab, PD‑1/PD‑L1 inhibitors, pemetrexed, PAH agents, ranibizumab, tocilizumab, ustekinumab (preferred products listed), viscosupplementation (preferred products listed), and many named brand products enumerated in the outpatient pharmaceuticals list.
For the reference product, all generics or biosimilar drugs will require a prior authorization; biosimilars are required in lieu of branded drugs and require prior authorization. Preferred biosimilars are required in lieu of branded drugs and members must try preferred products prior to non‑preferred approval.
Self‑injectables: Responsibility of the Medi‑Cal Rx Program; PA may be required and should be submitted via Cover My Meds or Prior Authorization Form (fax 800‑859‑4325). PA required from Pharmacy Services for self‑injectables administered in a physician's office.
Some specialty exceptions noted: e.g., bevacizumab agents (Avastin and biosimilars) — no PA required for ophthalmologists; certain rituximab and ESA/filgrastim products have specified PA exceptions when administered under the medical benefit or for specific specialties.
Non-benefit services requiring prior authorization
Non-benefit services that require prior authorization (CalAIM community supports examples).
Community supports (CalAIM) that are non‑benefit but require prior authorization or referral to CalAIM resources: assisted living facility transitions; asthma remediation; day habilitation; 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.
Limitations, exclusions, and prior authorization exceptions
Limitations, exclusions, and prior authorization exceptions for Medi‑Cal members including carve-outs, services not requiring PA, and sensitive services.
Carve‑out services (e.g., CCS‑eligible conditions) are not covered by Health Net and require authorization from the local CCS office; CCS services must be provided by CCS‑paneled providers at CCS‑approved facilities and any services related to CCS‑eligible conditions must be approved by the CCS program.
Routine laboratory and radiology services must be performed at a Health Net participating facility.
Specialty mental health services and select substance use disorder services are covered by the county mental health program; coordinate with Medi‑Cal Member Services for assistance.
ER services
- Emergency room services following stabilization of an emergency medical condition or when the medical screening exam does not demonstrate an emergency medical condition are subject to Health Net review and may not be paid.
Cosmetic surgery is not a Medi‑Cal benefit; requests are reviewed for possible reconstructive benefit and medical necessity per DHCS definition.
Services commonly included in the LEA carve‑out (speech, OT, audiology for children 3+, psychological testing for ADD/ADHD) are referred to the local school district.
A member or provider is not required to obtain prior authorization for non‑emergency medical transportation (NEMT) when transferring from an emergency room to an inpatient setting or immediately following inpatient acute stay to certain facilities (skilled nursing, intermediate care, embedded psychiatric units, free standing psychiatric inpatient hospitals, psychiatric health facilities, or other appropriate inpatient acute psychiatric facilities).
Hospice: Inpatient hospice care requires prior authorization; outpatient hospice routine home care, continuous home care, respite care, and hospice physician services do not require prior authorization (outpatient hospice documentation to be submitted via encrypted email to HospiceCTIforms@centene.com).
Prior authorization exceptions and requirements
Services and situations where prior authorization or referral is not required, and situations where prior authorization is required.
Minor consent services (age‑specific)
- No referral or prior authorization required for minor consent services: for children under age 12 — pregnancy and pregnancy‑related services, family planning, sexual assault services; for ages 12 and older (under 21) — pregnancy and pregnancy‑related services, family planning, sexual assault services, infectious/contagious/communicable disease diagnosis and treatment, sexually transmitted disease prevention/diagnosis/treatment, drug and alcohol abuse treatment and counseling, outpatient mental health treatment and counseling (if minor is determined mature per Family Code section 6924), and intimate partner violence.
CPSP outpatient abortion services: Prior authorization is not required for outpatient abortion services provided through the Comprehensive Perinatal Services Program (CPSP); services may be obtained from participating CPSP providers and information on locating a CPSP provider is available via the CPSP website.
Inpatient hospice care (requirement): Prior authorization is required for inpatient hospice care; submit required documentation to Health Net Prior Authorization per standard processes.
Outpatient hospice services (exception): Outpatient hospice services (routine home care, continuous home care, respite care, hospice physician services) do not require prior authorization; submit required documentation via encrypted email to HospiceCTIforms@centene.com.
Other specified services not requiring PA: Other services not requiring prior authorization include: basic prenatal care with a participating network obstetrician; California Prenatal Screening (PNS) program; preventive services from participating providers; services for emergency medical conditions; initial specialist referral (participating specialist); urgently needed services when the member is outside their county; certified nurse midwife and OB/GYN services from a participating provider; MOA 638 Indian Health Service facilities; FDA‑approved biomarker testing for advanced/metastatic stage 3 or 4 cancer; 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 participating providers.
Prior authorization contacts (resource): Directory of phone numbers, faxes, and specialty vendors (Evolent, TurningPoint, Coram, Transplant Team, Pharmacy Services, Behavioral Health Team, Modivcare, etc.) is available for authorization requests and referrals.
Codes, Pricing Thresholds, and Procedure Limits
Biosimilars and preferred biologics (named agent groups and guidance)mixedCovered
| Biosimilars are required in lieu of branded drugs; biosimilars require prior authorization; preferred biosimilars are required and members must try preferred products prior to non-preferred approval (authorized by Pharmacy Department). | |
| Bevacizumab agents: Alymsys®, Avastin®, Vegzelma®; Preferred = Mvasi®, Zirabev™ (no PA required for ophthalmologists). | |
| Erythropoiesis-stimulating agents (ESA): Aranesp®, Epogen®, Mircera®, Procrit®; Preferred = Retacrit™ (PA not required for Retacrit when administered/provided under the medical benefit). | |
| Filgrastim agents: Granix®, Neupogen®, Nypozi™, Releuko®; Preferred = Nivestym®, Zarxio® (PA not required for Zarxio when administered/provided under the medical benefit). | |
| Infliximab agents: Remicade®; Preferred = Avsola®, Inflectra®, Renflexis®. | |
| Pegfilgrastim agents: Fulphila®, Fylnetra®, Neulasta®, Neulasta OnPro®, Rolvedon™, Ryzneuta™, Stimufend®, Ziextenzo®; Preferred = Nyvepria®, Udenyca®, Udenyca Onbody. | |
| Rituximab agents: Riabni®, Rituxan®, Rituxan Hycela™; Preferred = Ruxience®, Truxima™ (no PA required for hematology/oncology indications). | |
| Trastuzumab agents: Enhertu®, Herceptin®, Herceptin Hylecta™, Hercessi™, Herzuma®, Kadcyla®, Ontruzant®; Preferred = Kanjinti®, Ogivri®, Trazimera™. |
Not specified in this sectionmixed
| No specific billing code specified in this section. |
inv-09: DME purchase price threshold (key facts)
DME purchase price thresholdItems with a total Medi‑Cal purchase price greater than $1,500 require prior authorization (PA).
Examples of DME subject to thresholdExamples include BiPAP, hospital beds and mattresses, power wheelchairs, scooters, ventilators, continuous glucose monitoring, custom-made items.
ApplicabilityApplies to adult and pediatric members as indicated in the DME section; providers must verify eligibility prior to ordering.
Where to submit PAPA requests should be submitted to Health Net using the contact information provided in the policy (fax, phone, or online).
inv-10: Rehabilitation visit authorization threshold (key facts)
Rehabilitation visit authorization thresholdPhysical, occupational, and speech therapy require authorization after 12 combined visits (includes home setting).
ScopeApplies to outpatient rehabilitation services including PT, OT, and speech-language pathology across applicable settings.
PA requirementAuthorization is required once the combined visit threshold is exceeded; continue to verify member eligibility and benefits.
Submission guidanceAttach treatment plans and supporting documentation to the PA request to demonstrate medical necessity.
inv-11: Full-source fallback (reference guidance)
Policy source and useThis policy lists services subject to prior authorization and is not a comprehensive covered‑services list; refer to the Evidence of Coverage for benefit determination.
How to submit requestsSubmit PA requests via fax, phone, or online to Health Net and include pertinent medical records, treatment plans, test results, and evidence of conservative treatment.
Timelines and notificationsElective/routine/urgent timelines and emergency notification requirements are described in the policy; emergencies require notification within 24 hours.
Fallback to full sourceWhen a specific local guidance or exception is unclear in summaries, consult the full policy document for exact PA designations, carve-outs, and contact details.
How to Request Prior Authorization and Provider Responsibilities
Prior Authorization
PA Submission Instructions
Submit a prior authorization (PA) request via fax, phone, or online using the contact information in the Prior Authorization Contacts section. Include pertinent medical records, treatment plans, test results, and documentation of conservative measures to support medical necessity. Failure to attach required documentation may delay processing. See Avoid Processing Delays for Prior Authorization Requests with These Guidelines for more details.
- Send requests to Health Net using the contact information in the Prior Authorization Contacts section (phone, fax, web).
- Attach medical records, treatment plans, test results, and evidence of conservative treatment.
- Encrypted email for hospice outpatient documentation: HospiceCTIforms@centene.com (see Hospice guidance).
Prior Authorization
PA Timelines
Submit PA requests according to the clinical urgency: elective, routine, or urgent. Emergency services do not require prior authorization but timely notification may still be required per hospital notification procedures.
- Elective inpatient or outpatient services: submit as soon as the need for service is identified.
- Routine requests/procedures: submit at least seven calendar days before the scheduled procedure.
- Urgent requests/procedures: submit within 72 hours before the scheduled procedure.
- Emergency services: do not require prior authorization; follow hospital notification requirements.
Prior Authorization
CPSP Services Prior Authorization Exception
Comprehensive Perinatal Services Program (CPSP) services and participating CPSP providers do not require prior authorization for outpatient abortion services. Providers and members may obtain these services from any participating CPSP provider. Refer to the CPSP website for provider location information.
- Outpatient abortion services via CPSP: prior authorization not required.
- Locate participating CPSP providers at: www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/CPSP.aspx
Prior Authorization
Hospice Prior Authorization Requirements
Inpatient hospice care requires prior authorization and must be submitted through the standard prior authorization process with required documentation attached. Outpatient hospice services (routine home care, continuous home care, respite care) and hospice physician services do not require prior authorization; required documentation for outpatient hospice should be submitted via encrypted email.
- Inpatient hospice care: prior authorization required. 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: prior authorization not required.
- Submit outpatient hospice required documentation via encrypted email to HospiceCTIforms@centene.com.
Terms and Carve-outs
inv-23: Prior Authorization — definition/key term
DefinitionPrior Authorization (PA) — A review and approval process required for certain services, procedures, equipment, and outpatient pharmaceuticals before they are provided to CHPIV Medi‑Cal FFS members.
PurposeEnsures medical necessity and eligibility prior to payment or provision of specified services.
Scope noteThe PA list indicates services that require PA only and is not a complete list of covered services; PA is guaranteed only as of the time of access to the list.
inv-24: Notification — definition/when required
DefinitionNotification — A requirement to inform Health Net of certain events (for example, emergency hospital admissions) rather than obtain prior approval.
When requiredEmergencies do not require PA but require notification within 24 hours; other notification requirements are specified in the policy's contact directory and timelines.
Provider responsibilityProviders must verify member eligibility prior to providing care and follow the notification/PA submission instructions in the policy.
inv-25: Carved out to Medi‑Cal FFS — services indication
Carve-out indicationCertain therapies are carved out to Medi‑Cal Fee‑for‑Service (FFS); effective 7/1/2025, gene therapies for sickle cell disease (including Casgevy™ and Lyfgenia™) are carved out to Medi‑Cal FFS.
Typical carve-outsCarve-outs may include high-cost gene therapies and other services as specified by DHCS and the policy; such services require authorization through Medi‑Cal FFS rather than Health Net.
Action for providersFor carved‑out services, obtain authorization from the responsible state/Medi‑Cal FFS entity per DHCS guidance rather than submitting PA to Health Net.
inv-26: CCS carve-out/authorization — key facts
CCS authorization requirementCalifornia Children's Services (CCS) covered conditions require authorization from the local CCS office; services must be provided by CCS‑paneled providers at CCS‑approved facilities.
ApplicabilityApplies to CCS‑eligible medical conditions; any services related to CCS‑eligible conditions must be approved by the CCS program per Title 22 regulations.
Provider actionRefer CCS‑eligible cases to the local CCS office for prior authorization and follow CCS program rules for provider paneling and facility approval.
inv-27: Minor consent services — services not requiring PA
Services minors may obtain without PAMinor consent services that do not require referral or prior authorization include pregnancy and pregnancy‑related services, family planning services, and sexual assault services for minors under age 12 and for ages 12 and older.
Additional services for ages 12+For minors age 12 and older (under 21), additional services not requiring PA include infectious disease diagnosis and treatment, STD prevention/diagnosis/treatment, drug and alcohol abuse treatment and counseling, and outpatient mental health treatment when the minor is deemed mature under Family Code section 6924.
Provider optionsThese sensitive services may be obtained from any qualified in‑network or out‑of‑network provider without PA or referral.
inv-28: CPSP — note on CPSP providers and outpatient abortion services
CPSP outpatient abortion servicesComprehensive Perinatal Services Program (CPSP) participating providers may provide outpatient abortion services without prior authorization.
Access and referralServices may be obtained from any participating CPSP provider; refer to the CPSP website for provider locations and participation details.
Policy noteOutpatient abortion services provided as CPSP services are explicitly listed as not requiring prior authorization in the policy.
Policy Summary
PayerCentene (Health Net / CHPIV)
PolicyPrior Authorization Requirements for CHPIV Medi‑Cal FFS Members
Policy CodePolicy N/A
Change TypeAdministrative (no material clinical changes)
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionSubmit PA requests via fax, phone, or online to Health Net and attach medical records, treatment plans, test results, and evidence of conservative treatment.
SourceLink
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