Prior Authorization Requirements for CHPIV Medi‑Cal FFS Services
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This document lists services, procedures, equipment, and outpatient pharmaceuticals that require prior authorization (PA) for Community Health Plan of Imperial Valley (CHPIV) Medi‑Cal fee‑for‑service members and explains submission, timelines, and related eligibility responsibilities.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization
PA coverage criteria (partial)
Items and services requiring prior authorization (selected highlights from the PA list):
Outpatient pharmaceuticals and coverage rules
Outpatient pharmaceuticals submitted under the medical benefit that may require prior authorization (selected rules and examples):
Selected exceptions/notes
- Bevacizumab agents: no PA required for ophthalmologists for certain indications (preferred biosimilars noted).
- Certain agents such as rituximab may have no PA for specific hematology/oncology indications per the listing.
Prior authorization exceptions and hospice limits
Services and circumstances that are exempt from referral or prior authorization, and hospice authorization rules:
No prior authorization required
- Minor consent services: Pregnancy and pregnancy-related services, family planning services, and sexual assault services for minors (specified by age groups) do not require referral or prior authorization and may be obtained from any qualified in‑network or out‑of‑network provider.
- Additional minor services (age 12 and older under 21): Infectious/communicable disease diagnosis and treatment, sexually transmitted infection prevention/diagnosis/treatment, drug and alcohol treatment and counseling, outpatient mental health treatment and counseling (if minor is determined mature per Family Code section 6924).
- Comprehensive Perinatal Services Program (CPSP) services: No prior authorization required; services may be obtained from any participating CPSP provider.
- Other services not requiring prior authorization: Basic prenatal care with participating obstetrician, California Prenatal Screening, preventive services from participating providers, services for emergency medical conditions, initial specialist referral, urgently needed services outside the member's county, certified nurse midwife/OB‑GYN services from a participating provider, MOA 638 IHS facilities, FDA‑approved biomarker testing for advanced/metastatic stage 3 or 4 cancer, COVID‑19 diagnostic/screening testing, Children and Youth Behavioral Health Initiative fee schedule services, and initial mental health and substance use disorder assessments.
Coding, Thresholds and Durable Medical Equipment Rules
| 0457U | Proprietary laboratory analysis code 0457U |
| 0459U | Proprietary laboratory analysis code 0459U |
| 0462U | Proprietary laboratory analysis code 0462U |
| 0468U | Proprietary laboratory analysis code 0468U |
| 0472U | Proprietary laboratory analysis code 0472U |
| 0577U | Proprietary laboratory analysis code 0577U |
| 0579U | Proprietary laboratory analysis code 0579U |
| 0591U | Proprietary laboratory analysis code 0591U |
| 0596U | Proprietary laboratory analysis code 0596U |
| 0598U | Proprietary laboratory analysis code 0598U |
| UNLISTED | Services or procedures without a specific code are categorized as unlisted services and require appropriate coding and documentation. |
| * | Unlisted services and procedures: Services or procedures without a specific code are billed using appropriate unlisted codes and require documentation per payer guidelines. |
How to Submit Prior Authorizations and Operational Notes
Prior Authorization Submission Instructions
Submit a PA request - Send the request via fax, phone or online. The request should be submitted to Health Net using the contact information on page 15 unless noted differently in the requirements list. Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. For more submission instructions, see Avoid Processing Delays for Prior Authorization Requests with These Guidelines.
- Submit via fax, phone or online using the contact information on page 15.
- Attach medical records, treatment plans, test results, and evidence of conservative treatment.
Prior Authorization Submission Timelines
PA timelines - Elective inpatient or outpatient services: submit as soon as the need for service is identified. Routine requests/procedures: submit at least five business days before a scheduled procedure. Urgent requests/procedures: submit at least 72 hours before a scheduled procedure. Emergency services do not require prior authorization.
- Elective (inpatient or outpatient): Submit as soon as need identified.
- Routine: Submit at least 5 business days before scheduled procedure.
- Urgent: Submit at least 72 hours before scheduled procedure.
- Emergency services: No prior authorization required.
Documentation and Eligibility Verification
Documentation and eligibility verification - Attach supporting documentation with the PA request and verify member eligibility to avoid processing delays. Pertinent documentation includes medical records, treatment plans, test results, evidence of conservative treatment, and any hospice- or CCS-related approvals when applicable.
- Verify member eligibility before submitting the PA.
- Include all supporting documentation to substantiate medical necessity.
Wound Care Prior Authorization Threshold
Wound care prior authorization threshold - Wound care services, including negative pressure wound therapy, low-frequency ultrasound, skin substitutes/biologics, and wound debridement, require prior authorization after 12 sessions per year.
- Wound debridement and other wound care modalities: authorization required after 12 sessions per year.
CCS Carve-Out Prior Authorization
Prior authorization for carve-out CCS services - Authorization for carve-out services not covered by Health Net, such as CCS-eligible conditions, requires prior authorization from the local CCS office. CCS services must be provided by CCS-paneled providers and at CCS-approved facilities. Any services related to CCS-eligible medical conditions must be approved by the CCS program per California Code of Regulations, Title 22.
- CCS-eligible conditions: PA must be obtained from the local CCS office.
- CCS services must be delivered by CCS-paneled providers at CCS-approved facilities.
Hospice Prior Authorization Rules
Hospice prior authorization rules - Inpatient hospice care requires prior authorization subject to Health Net's standard prior authorization processes. Attach the required documentation and submit to Health Net - Prior Authorization. Outpatient hospice services (routine home care, continuous home care, respite care) and hospice physician services do not require prior authorization; submit required documentation via encrypted email to HospiceCTIforms@centene.com.
- 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) and hospice physician services: No prior authorization required; submit documentation via encrypted email to HospiceCTIforms@centene.com.
Minor Consent and Sensitive Services — No Prior Authorization
Minor consent and sensitive services - no prior authorization required - Referral or prior authorization is not required for specified minor consent and sensitive services. These services may be obtained from any qualified in-network or out-of-network provider and include: pregnancy and pregnancy-related services, family planning services, sexual assault services, infectious/contagious disease diagnosis and treatment, sexually transmitted disease prevention/diagnosis/treatment, drug and alcohol abuse treatment and counseling, outpatient mental health treatment and counseling (when the attending professional determines the minor is mature enough pursuant to Family Code section 6924), sexual assault care, outpatient abortion services, and Comprehensive Perinatal Services Program (CPSP) services from participating CPSP providers.
- Minor consent services (under age 12 and ages 12–20) including pregnancy-related care, family planning, and sexual assault services: No PA required.
- Ages 12 and older (under 21): Also includes infectious disease treatment, STD prevention/diagnosis/treatment, substance use treatment/counseling, and outpatient mental health treatment when appropriate per Family Code section 6924.
- Sexual assault care and outpatient abortion services: No PA required.
- Comprehensive Perinatal Services Program (CPSP) services: No PA required when obtained from participating CPSP providers.
Definitions and Program Notes
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