Prior Authorization (PA) requirements list for CHPIV Medi‑Cal FFS members
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Governs prior authorization and notification requirements for services, procedures, equipment, and outpatient pharmaceuticals for Community Health Plan of Imperial Valley (CHPIV) Medi‑Cal fee‑for‑service members in Imperial County; affects providers who must verify eligibility and submit PA requests as specified.
No material clinical or coverage changes in this revision.
Coverage criteria and services requiring prior authorization
Example PA criteria nodes
Selective examples from the PA list showing service categories and PA status for adult and pediatric members:
ALL of the following
- PA status (Adult Members age 21 and over): PA required; includes acute care hospital and acute/sub‑acute rehabilitation; certain adult musculoskeletal procedures authorized by TurningPoint Healthcare Solutions, LLC.
- PA status (Pediatric Members under age 21): PA required; emergency situations do not require PA but notification required within 24 hours.
ALL of the following
- PA status (Adult Members): PA required for elective admissions; contact Long‑Term Care Intake Line.
- PA status (Pediatric Members): PA required.
ALL of the following
- PA status (Adult Members): PA required (advanced and cardiac imaging requests authorized by Evolent Specialty Services, Inc.).
- PA status (Pediatric Members): PA required (all cardiac procedures for pediatric members require PA).
ALL of the following
- PA status (Adult Members): PA required for listed items and for items with total Medi‑Cal purchase price greater than $1,500.
- PA status (Pediatric Members): PA required for listed DME.
ALL of the following
- PA status (Adult Members): Authorization required after 12 visits (i.e., authorization required when visits exceed 12).
- PA status (Pediatric Members): PA required; EPSDT/pediatric considerations apply.
ALL of the following
- PA status (Adult Members): Varies by procedure; some adult outpatient elective surgeries require PA through specialty vendors (e.g., TurningPoint for certain spinal procedures).
- PA status (Pediatric Members): All outpatient elective surgery requires PA.
Coverage criteria and prior authorization requirements for listed services and drugs
Coverage stance and prior authorization requirements for outpatient pharmaceuticals and specialized therapies.
ALL of the following
- Notes: Examples listed (Abecma, Breyanzi, Kymriah, Yescarta, Zolgensma, etc.); effective 7/1/2025, gene therapies for sickle cell disease (Casgevy, Lyfgenia) are carved out to Medi‑Cal FFS through DHCS.
ALL of the following
- Notes: Examples listed include Amondys‑45, Exondys‑51, Viltepso, Vyondys‑53.
ALL of the following
- Notes: Examples listed include Keytruda, Opdivo, Tecentriq and others; contact Pharmacy Services for details and authorization.
ALL of the following
- Notes: Biosimilars are required in lieu of branded drugs; preferred biosimilars must be tried prior to non‑preferred approval; authorized by the Pharmacy Department; see drug‑specific policy for preferred lists.
ALL of the following
- Notes: Contact Pharmacy Services to confirm PA requirements for newly approved medications; self‑injectables may be subject to Medi‑Cal Rx program rules and PA processes.
ALL of the following
- Notes: Requests (including evaluations, consults, donor search, transplant procedure) must be faxed to the Transplant Team and require PA.
ALL of the following
- Notes: These Community Supports are listed as non‑benefit services requiring prior authorization; refer to CalAIM resources for details.
ALL of the following
- Notes: Routine lab and radiology must be performed at a Health Net participating facility per network/provider requirements.
ALL of the following
- Notes: Cosmetic surgery is not a Medi‑Cal benefit; requests are reviewed for reconstructive benefit and medical necessity using DHCS definition.
Prior authorization requirements and exceptions
Rules describing which services are exempt from prior authorization and which require it.
ALL of the following
- Includes: pregnancy and pregnancy‑related services; family planning; sexual assault services; infectious/communicable disease diagnosis and treatment; STI prevention/diagnosis/treatment; drug and alcohol abuse treatment and counseling; outpatient mental health treatment for mature minors (per Family Code §6924).
Codes, thresholds, and coding-related limits
| 0457U | Proprietary laboratory analyses CPT® codes listed in document |
| 0459U | Proprietary laboratory analyses CPT® codes listed in document |
| 0462U | Proprietary laboratory analyses CPT® codes listed in document |
| 0468U | Proprietary laboratory analyses CPT® codes listed in document |
| 0472U | Proprietary laboratory analyses CPT® codes listed in document |
| 0577U | Proprietary laboratory analyses CPT® codes listed in document |
| 0579U | Proprietary laboratory analyses CPT® codes listed in document |
| 0591U | Proprietary laboratory analyses CPT® codes listed in document |
| 0596U | Proprietary laboratory analyses CPT® codes listed in document |
| 0598U | Proprietary laboratory analyses CPT® codes listed in document |
| Abrilada™ | Outpatient pharmaceutical listed in document |
| Adakveo® | Outpatient pharmaceutical listed in document |
| Adcetris® | Outpatient pharmaceutical listed in document |
| Adzynma™ | Outpatient pharmaceutical listed in document |
| Akynzeo® | Outpatient pharmaceutical listed in document |
| Aliqopa™ | Outpatient pharmaceutical listed in document |
| Amtagvi™ | Outpatient pharmaceutical listed in document |
| Amvuttra® | Outpatient pharmaceutical listed in document |
| Anktiva® | Outpatient pharmaceutical listed in document |
| Aphexda | Outpatient pharmaceutical listed in document |
Provider submission, notifications, and authorization actions
How to submit a PA request
Send the prior authorization request via fax, phone, or online to Health Net using the contact information on page 16. Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support medical appropriateness. See the submission guidelines referenced in the policy to avoid delays.
- Submit via fax, phone, or online to Health Net (use page 16 contact information).
- Attach medical records, treatment plans, test results, and evidence of conservative treatment.
PA timelines and emergency notification
Submit routine PA requests as soon as the need is identified and at least seven calendar days before a scheduled procedure; submit urgent requests at least 72 hours before a scheduled procedure. Emergency services do not require prior authorization but require notification (see hospital notification rules).
- Routine: as soon as need identified; at least 7 calendar days before scheduled procedure.
- Urgent: 72 hours before scheduled procedure.
- Emergency services: PA not required.
Notification contacts and special lines
Use the specified contact lines for special notifications and routing: send inpatient and post-stabilization notifications to the Hospital Notification Unit (fax and phone lines listed), and route long‑term care admissions to the Long‑Term Care Intake Line. Transplant requests are accepted via fax to the Transplant Team.
- Hospital Notification Unit: fax and post-stabilization lines (see contacts).
- Long-Term Care Intake Line: 800-453-3033; fax: 855-851-4563.
- Transplant requests: fax to Transplant Team (fax: 833-769-1141).
Out‑of‑network provider authorization
Services rendered by out‑of‑network providers require prior authorization except for emergency services and certain self‑referral services allowed under the Medi‑Cal plan (e.g., family planning, pregnancy termination, HIV testing).
- Out‑of‑network services require PA.
- Exceptions: emergency services and Medi‑Cal self‑referral services listed in policy.
Surgery prior authorization handling
All outpatient elective surgery for pediatric members requires prior authorization. Adult spinal surgery authorizations are handled by TurningPoint Healthcare Solutions, LLC; pediatric spinal surgery is authorized by Health Net on behalf of CalViva Health.
- Pediatric outpatient elective surgery: PA required for all procedures.
- Adult spinal surgery: authorized by TurningPoint Healthcare Solutions, LLC.
- Pediatric spinal surgery: authorized by Health Net on behalf of CalViva Health.
Transplant prior authorization instructions
Fax transplant requests to the Transplant Team; transplant evaluations and procedures—including evaluations, consult visits, donor search, and the transplant procedure—require prior authorization.
- Fax requests to the Transplant Team (see contact fax).
- Prior authorization required for transplant evaluations, consults, donor search, and transplant procedures.
New outpatient pharmaceuticals prior authorization
Medications newly approved by the U.S. FDA may require prior authorization; contact Pharmacy Services to confirm whether PA is required for a new outpatient pharmaceutical.
- Newly FDA‑approved medications: may require PA.
- Contact Pharmacy Services to confirm PA requirements.
Transportation prior authorization
All non‑emergency medical transportation (NEMT) requires a Physician Certification Statement (PCS) and authorization by the Care Ride Unit; ground NEMT is authorized by the Care Ride Unit and air ambulance authorization is handled by Health Net on behalf of CalViva Health.
- NEMT requires a Physician Certification Statement (PCS).
- Ground NEMT authorized by Care Ride Unit; air ambulance authorized by Health Net on behalf of CalViva Health.
Biosimilar prior authorization requirement
Biosimilars require prior authorization and are required in lieu of branded drugs; preferred biosimilars must be tried prior to approval of non‑preferred products. Authorization is handled by the Pharmacy Department.
- Biosimilars: require PA and are required instead of branded drugs.
- Preferred biosimilars must be tried before non‑preferred approval.
- Authorized by the Pharmacy Department.
Hospice prior authorization rules
Inpatient hospice care requires prior authorization under Health Net's standard PA processes; outpatient hospice routine home care, continuous home care, respite care, and hospice physician services do not require prior authorization but required documentation must be submitted via the specified encrypted email.
- Inpatient hospice care: PA required; attach required documentation and submit to Health Net Prior Authorization.
- Outpatient hospice services (routine home care, continuous home care, respite care, hospice physician services): no PA required; submit documentation via encrypted email to HospiceCTIforms@centene.com.
NEMT transfer exception
A prior authorization is not required for NEMT when transferring a member from an emergency room to an inpatient setting or when transferring immediately following an inpatient stay to certain post‑acute facilities (skilled nursing, intermediate care, inpatient psychiatric facilities, etc.).
- No NEMT PA required for ER-to-inpatient transfers.
- No NEMT PA required for immediate post‑inpatient transfers to skilled nursing, intermediate care, or specified psychiatric facilities.
Sensitive services and other no-prior-auth categories
Referral or prior authorization is not required for listed sensitive services and minor‑consent categories (pregnancy‑related care, family planning, sexual assault care, STI/infectious disease diagnosis and treatment, substance use treatment, outpatient mental health for mature minors), CPSP services, initial specialist referrals, emergency services, certain preventive services, and other specified services described in the policy.
- Minor consent services (pregnancy, family planning, sexual assault care) do not require referral/PA.
- CPSP services and certain preventive, emergency, and initial specialist/referral services do not require PA.
- Outpatient abortion services and sexual assault care do not require PA.
Prior authorization contacts
Use the primary prior authorization request phone, fax, and web portal for general PA submissions; route specialty requests to the listed teams (Behavioral Health Team, Evolent for advanced/cardiac imaging, Care Ride Unit for NEMT, Transplant Team, TurningPoint for musculoskeletal requests). Pharmacy Services handles drug‑related authorizations.
- General PA requests: 833-236-4141; fax: 800-743-1655; provider.healthnetcalifornia.com.
- Care Ride Unit (NEMT prior authorization): fax 833-701-0051; Modivcare scheduling: 855-251-7097.
- Evolent (advanced/cardiac imaging): 855-510-3720; online: www.radmd.com.
- Transplant Team fax: 833-769-1141; TurningPoint musculoskeletal: 855-332-5898; Pharmacy Services: 800-867-6564, option 2; fax: 833-953-3436.
Definitions, carve-outs, and limitations
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