Submission routes and required attachments

Submit prior authorization requests via fax, phone or online using the contact information on page 16 (see Prior Authorization Contacts). Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support medical appropriateness.

• Send request to Health Net using contact information on page 16 unless noted otherwise.
• Include pertinent medical records, treatment plans, test results, and evidence of conservative treatment with the request.
• Use vendor-specific routes where noted (e.g., Evolent portal for advanced imaging, TurningPoint for musculoskeletal).

PA timelines and emergency notification

Follow the PA timing rules: submit as soon as need is identified for elective inpatient/outpatient; routine requests at least 7 calendar days before scheduled procedures; urgent requests 72 hours before. Emergency services do not require prior authorization but the plan must be notified within 24 hours of admission.

• Elective inpatient/outpatient — submit as soon as need is identified.
• Routine — submit at least 7 calendar days before scheduled procedure.
• Urgent — submit 72 hours before scheduled procedure.
• Emergency hospitalizations — notification required within 24 hours to the Hospital Notification Unit.

Verify eligibility; PA does not change benefit limits

Verify member eligibility through the Provider Services Center before providing care; an approved prior authorization does not override member eligibility rules or benefit limitations.

• Providers are responsible for verifying eligibility prior to care.
• Authorization does not change applicability of eligibility rules or plan benefit limits.

Transplant PA routing and required content

Fax transplant prior authorization requests to the Transplant Team and include transplant evaluations and procedures (evaluation, transplant consult visits, donor search, and transplant procedure) in the submission.

• Fax requests to the Transplant Team (fax: 833-769-1141).
• Include transplant evaluations, consult visits, donor search documentation, and planned transplant procedure details.

NEMT authorization and required PCS

All non‑emergency medical transportation (NEMT) requires a Physician Certification Statement (PCS). Ground NEMT authorization is managed through the Care Ride Unit; air ambulance authorization is handled by Health Net. Modivcare schedules NEMT/NMT ground rides.

• Provide a Physician Certification Statement (PCS) for NEMT requests.
• Ground NEMT authorized by Care Ride Unit (Care Ride fax: 833-701-0051).
• Air ambulance authorized by Health Net on behalf of CalViva Health.
• Modivcare scheduling: 866-529-2128; fax 877-457-3352.

New medications — check with Pharmacy Services

Newly FDA‑approved medications may require prior authorization; contact Pharmacy Services to determine PA requirements before prescribing.

• New FDA‑approved drugs: may require PA — contact Pharmacy Services to confirm.
• Pharmacy Services phone: 800-867-6564; fax: 833-953-3436.

Self‑injectable PA routing and submission

Self‑injectable medications fall under the Medi‑Cal Rx program; PA may be required and Pharmacy Services authorizes self‑injectables administered in a physician's office. Use Cover My Meds or fax the prior authorization form to submit requests per Medi‑Cal Rx guidance.

• Self‑injectables are the responsibility of the Medi‑Cal Rx Program; refer to the DHCS Contract Drug List.
• Use Cover My Meds or fax a Prior Authorization Form to 800-859-4325 for Medi‑Cal Rx submissions.
• Pharmacy Services authorizes office‑administered self‑injectables.

Biosimilar substitution and PA expectation

Use biosimilars in lieu of branded biologic drugs when available; biosimilars require prior authorization and preferred biosimilars must be tried prior to non‑preferred product approval.

• Biosimilars are required in lieu of branded drugs.
• Biosimilars require prior authorization.
• Preferred biosimilars are required before non‑preferred products will be approved.

No separate authorization/denial rules in these fragments

No additional explicit authorization or denial rules are provided in the repeated informational fragments; follow the document's PA criteria, timelines, exceptions and contact routes for determinations.

• The source fragments do not provide separate denial rules beyond the PA list and exceptions.
• Providers must rely on the PA criteria, timelines, eligibility rules, and contact points in this document.

Reaffirm biosimilar substitution requirement

Biosimilar substitution is reiterated: providers must substitute biosimilars for branded biologics when available and follow PA requirements for biosimilars.

• Biosimilars are required in lieu of branded drugs (repeated statement).
• Age applicability and PA indicators are noted elsewhere for specific items.

Biosimilar substitution — provider expectation

Biosimilar substitution expectation is repeated across the policy: clinicians should expect to use biosimilars in place of branded biologics and seek PA where required.

• Biosimilars required in lieu of branded drugs (policy repeated).
• Obtain prior authorization for biosimilars when indicated.

CCS carve‑out services require CCS prior authorization

Services carved out to California Children's Services (CCS) require prior authorization from the local CCS office and must be delivered by CCS‑paneled providers at CCS‑approved facilities; CCS program approval is required for CCS‑eligible conditions.

• Obtain prior authorization from the local CCS office for CCS‑carved‑out services.
• Services must be provided by CCS‑paneled providers at CCS‑approved facilities.
• Refer to CCR Title 22, Division 2, Part 2, Subdivision 7, CCS for medical eligibility.

Perform routine labs/radiology at participating facilities

Routine laboratory and radiology services must be performed at a Health Net or CalViva Health participating facility.

• Ensure routine labs and radiology are scheduled at participating facilities to comply with policy.

Prior‑authorization exceptions — sensitive and perinatal services

No prior authorization is required for listed sensitive and perinatal services (minor consent services such as pregnancy‑related care, family planning, sexual assault services; outpatient abortion and CPSP services are also exempt).

• Minor consent services (pregnancy, family planning, sexual assault) do not require referral/PA and may be obtained from any qualified provider.
• Outpatient abortion services and Comprehensive Perinatal Services Program (CPSP) services do not require PA.

County‑covered specialty MH/SUD services — contact county program

Specialty mental health and select substance use disorder services are covered by the county mental health program; contact Medi‑Cal Member Services or county mental health for coordination and access.

• County mental health covers specialty MH/SUD services; contact county mental health for service access.
• Contact Medi‑Cal Member Services for coordination assistance.

Urgent/out‑of‑county exceptions — no PA required

Urgently needed services when a member is outside their county and certain provider categories (e.g., certified nurse midwife, participating OB/GYN) do not require prior authorization.

• Urgently needed services while outside the member's county are exempt from PA.
• Certified nurse midwife and participating OB/GYN services from participating providers do not require PA.

Services exempt from PA — selected list

Other routine services that do not require prior authorization include basic prenatal care with a participating network obstetrician, California Prenatal Screening (PNS), preventive services from participating providers, emergency services, initial specialist referral, biomarker testing for advanced/metastatic stage 3 or 4 cancer (FDA approved), COVID‑19 testing, initial MH/SUD assessments, adult preventive immunizations, and second opinions.

• Basic prenatal care with participating network obstetrician — no PA required.
• Biomarker testing for advanced/metastatic stage 3 or 4 cancer (FDA approved) — no PA required.
• Initial mental health and substance use disorder assessments and adult preventive immunizations — no PA required.

Continuity/transfer documentation required for eligibility and transfers

When verifying continued eligibility or transferring a patient between health plans, supply a face‑to‑face encounter document that verifies clinical evaluation and a transfer summary when the patient changes health plan carriers (see APL 25‑008 for details).

• Provide a face‑to‑face encounter document verifying clinical evaluation for continued eligibility.
• Provide a transfer summary when the patient changes health plan carriers; refer to APL 25‑008 for additional guidance.

PA contacts and submission routes (phone, fax, web, vendor portals)

Prior authorization requests and related inquiries may be submitted by phone, fax, or web portal; contact numbers and vendor routes are provided for general PA requests, hospital notification, Long‑term Care intake, Behavioral Health, Coram, Evolent (radMD portal), Transplant Team (fax), TurningPoint (musculoskeletal), Nurse Advice Line, Pharmacy Services, Modivcare (NEMT), Provider Services Center, CCS and Public Programs.

• General prior authorization: 888‑893‑1569; fax 800‑743‑1655; portal: provider.healthnetcalifornia.com.
• Hospital notification fax: 800‑676‑7969; post‑stabilization phone: 800‑995‑7890.
• Care Ride Unit (NEMT prior auth) fax: 833‑701‑0051; Modivcare scheduling 866‑529‑2128; fax 877‑457‑3352.
• Pharmacy Services: 800‑867‑6564 (option 2); fax 833‑953‑3436. Transplant Team fax: 833‑769‑1141. Evolent portal: www.radmd.com. TurningPoint phone: 855‑332‑5898; fax 949‑774‑2254.