PA submission requirements

Submit prior authorization (PA) requests via fax, phone, or the online provider portal. Send requests to Health Net using the contact information in the Prior Authorization Contacts unless a different vendor is specified for that service. Include pertinent medical records, treatment plans, diagnostic test results, and documentation of conservative therapy where applicable to support medical necessity. See the provider guidance Avoid Processing Delays for Prior Authorization Requests with These Guidelines for additional submission tips.

• Include supporting documentation: medical records, treatment plans, test results, evidence of conservative treatment

PA submission timelines

Timelines: submit routine prior authorization requests at least five business days before a scheduled procedure. Submit urgent requests at least 72 hours before a scheduled procedure. For elective inpatient or outpatient services, submit as soon as the need for the service is identified. Emergency services do not require prior authorization.

• Elective inpatient/outpatient: submit as soon as need identified
• Routine: ≥ 5 business days before scheduled procedure
• Urgent: ≥ 72 hours before scheduled procedure
• Emergency services: PA not required

Hospital notification for emergency admissions

For inpatient emergency admissions, providers must notify Health Net by contacting the Hospital Notification unit (fax or phone) within 24 hours of admission. This is a notification requirement only and does not constitute a routine prior authorization.

• Hospital Notification Fax Line: fax: 800-676-7969
• Hospital Notification/Post-stabilization Notification phone: 800-995-7890

Third‑party authorization routing

Some services require routing through specialty authorization vendors or carve‑out programs. Follow vendor-specific routing when indicated in the requirements list (examples below). If a service is carved out (e.g., CCS, county mental health, LEA services), obtain authorization from the designated program or local office.

• CCS (California Children’s Services): obtain PA from local CCS office; CCS paneling and approvals required
• Carve-outs (LEA, county mental health, etc.): refer to the responsible agency for authorization

Prior authorization notes for new drugs and self‑injectables

Medications newly approved by the FDA may require prior authorization. Contact Pharmacy Services to confirm PA requirements for newly approved drugs. Self‑injectable medications are managed through the Medi‑Cal Rx Program; however, PA may be required for self‑injectables administered in a physician’s office — submit via CoverMyMeds or fax a completed Prior Authorization Form to Pharmacy Services.

• Newly FDA‑approved medications: contact Pharmacy Services to confirm PA
• Self‑injectables: managed by Medi‑Cal Rx; PA may be required for office‑administered self‑injectables
• CoverMyMeds or fax PA form to 800-859-4325; Pharmacy Services phone: 800-867-6564, option 2; fax: 833-953-3436

Prior authorization exceptions and carve‑outs

Certain services and populations are exempt from prior authorization. Examples include: sensitive/minor consent services (family planning, pregnancy-related services, sexually transmitted infection treatment, substance use treatment, some outpatient mental health), Comprehensive Perinatal Services Program (CPSP) services, selected preventive and pediatric services, and specified carve‑outs such as CCS and county mental health. Routine lab and radiology must be performed at participating facilities; check the limitations and exclusions for full details.

• No PA required for minor consent services and specified sensitive services
• CPSP services: no referral or PA required — obtain from any participating CPSP provider
• CCS‑eligible services: obtain authorization from local CCS office (carve‑out)
• Some NEMT transfers between specific settings do not require PA (see Limitation and Exclusions)

How to request prior authorization / contact points

How to request prior authorization: call the PA phone number, fax the request, or submit online through the provider portal. Use the vendor-specific contact information for services routed to specialty vendors (listed below). For general Medi‑Cal prior authorization or member questions, refer to the member services number on the member’s ID card.

• General Prior Authorization: phone 888-893-1569; fax 800-743-1655; provider.healthnetcalifornia.com
• Hospital Notification Unit fax: 800-676-7969; post‑stabilization phone: 800-995-7890
• Long‑term Care Intake Line: 800-453-3033; fax: 855-851-4563

Special-case services referenced

Special-case services referenced in the PA requirements include biomarker testing for advanced/metastatic (stage 3–4) cancer (FDA‑approved tests), COVID‑19 diagnostic and screening testing, transplant evaluations and procedures, and services rendered under specific initiatives or carve‑outs. Verify PA requirements and routing for these services as they may be handled by specialty teams or external programs.

• Biomarker testing for advanced/metastatic cancer (FDA‑approved)
• COVID‑19 diagnostic and screening testing
• Transplant evaluations and procedures: fax requests to the Transplant Team

Vendor-specific prior authorization routing

Vendor‑specific routing and contact points — use the designated vendor for the listed service types:

• Coram Specialty Infusion Services (preferred home infusion): 866-899-1661; fax: 866-843-3221
• Evolent Specialty Services (advanced and cardiac imaging): 800-424-4809; online: www.radmd.com
• TurningPoint Healthcare Solutions (musculoskeletal requests): 855-332-5898; fax: 949-774-2254; www.myturningpoint-healthcare.com; email: centenecaum@turningpoint-healthcare.com
• Pharmacy Services (biosimilars and other pharmacy‑managed drugs): 800-867-6564, option 2; fax: 833-953-3436
• Transplant Team fax: 833-769-1141

Transportation scheduling

Transportation scheduling and NEMT/NMT authorization: non‑emergency and non‑medical ground transportation scheduling is handled by Modivcare. All NEMT requires a Physician Certification Statement (PCS) for authorization; ground NEMT (ambulance, ambulatory door‑to‑door, gurney/stretcher, wheelchair) is authorized by the Care Ride Unit. Air ambulance requires prior authorization by Health Net when applicable.

• Modivcare scheduling: 866-529-2128; fax: 877-457-3352
• Care Ride Unit (NEMT prior authorization) fax: 833-701-0051
• PCS required for NEMT authorization; air ambulance authorized by Health Net