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    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyPHC California Self-Referral Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentPHC CaliforniaPolicy N/A

    Access to Self-Referred Covered Services

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    Defines covered services that enrollees may access without prior authorization or a primary care provider referral, including special rules for out-of-network access, family planning, pregnancy termination, STI and HIV services, immunizations, and sensitive services.

    Policy Summary
    PayerPHC California
    PolicyAccess to Self-Referred Covered Services
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMarch 1, 2008
    Last ReviewOct 15, 2025
    Next Review DateN/A
    Key ActionProvide covered self-referred services without prior authorization or a provider referral, subject to stated limits and exceptions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    15Self-referred service categories
    2 visits/monthChiropractic limit
    1 visit/episodeCommunity-provider STI limit
    NoneAmerican Indian IHCP cost sharing

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    9 months
    Assault-care cost-sharing protection
    AnnualReview cycle

    Covered Self-Referred Services and Exceptions

    Covered self-referred services

    Services are accessible by self-referral when they fall within a covered service category and comply with applicable limits and exceptions.

    Covered self-referred services include

    • Primary care provider visits; preventive care; urgent or emergency care, including behavioral health and substance use disorder services; and initial mental health assessments are available without prior authorization or a provider referral.
    • Emergency and follow-up health care after rape or sexual assault, sensitive and confidential services, confidential HIV testing and counseling, and treatment of sexually transmitted infections are available under the self-referral policy.
    • Family planning services and obstetrics/gynecology care are available, including access to qualified out-of-network family planning providers without prior authorization.
    • Therapeutic and elective pregnancy termination performed as a physician service is covered without medical justification or prior authorization, subject to the non-emergency inpatient hospitalization exception.
    • Immunizations, including access through local health departments, are available without prior authorization and are provided under applicable immunization requirements.
    • Services provided by certified nurse practitioners within the scope of practice authorized by California law are available without prior authorization or a provider referral.
    • Qualifying chiropractic services and routine eye examinations are available without prior authorization, subject to the chiropractic visit limit and applicable out-of-network referral rule.

    Coverage limits and exceptions

    The following restrictions and special rules apply despite the general self-referral policy.

    Applicable limits and exceptions include

    • Chiropractic services are available without authorization for a maximum of two services per calendar month.Maximum of 2 services per calendar month

      Authorization is required for services exceeding the monthly limit. A referral may be required when chiropractic services are provided by out-of-network FQHCs, RHCs, or IHCPs.

    • Covered physician-performed pregnancy termination does not require medical justification or prior authorization.

      Non-emergency inpatient hospitalization for the termination requires admission authorization and review under acute inpatient criteria.

    • Out-of-network services for STI diagnosis and treatment may be obtained through local health departments, family planning clinics, and community STI providers when the service is within policy scope.1 visit per STI episode

    Service Limits and Cost-Sharing Rules

    Chiropractic services without authorization
    Service categoryChiropractic services rendered by a chiropractor, as described in the Medi-Cal Provider Manual
    Limit without authorizationMaximum of two services per calendar month
    Authorization requirementAuthorization is required for chiropractic services that exceed the two-visit-per-month limit
    Community-provider STI services
    Visit limitFor community providers other than the Local Health Department, one visit per sexually transmitted infection episode
    Clinical indicationThe limit applies when immediate diagnosis and treatment are clinically indicated

    Operational Requirements for Providers

    Prior Authorization

    Honor the self-referral service list

    Provide the listed covered services through self-referral without requiring prior authorization or a provider referral, subject to applicable service limits and exceptions.

    • PCP visits; preventive, urgent, and emergency care, including behavioral health and substance use disorder services
    • Emergency and follow-up care after rape or sexual assault; confidential HIV testing and counseling; STI treatment
    • Family planning; obstetrics/gynecology care; therapeutic and elective pregnancy termination; initial mental health assessment
    • Sensitive and confidential services; immunizations; qualifying certified nurse practitioner services; routine eye exams; qualifying chiropractic services
    Prior Authorization

    Apply the chiropractic visit threshold

    Authorization is required for chiropractic services that exceed two visits per calendar month. A referral may be required when chiropractic services are provided by out-of-network FQHCs, RHCs, or IHCPs.

    Key Service Definitions

    Informed consent
    DefinitionInformed consent is consent obtained from enrollees for all contraceptive methods
    Included methodThe requirement includes sterilization
    California regulatory basisTitle 22, California Code of Regulations, Sections 51305.1 and 51305.3
    Minor Consent Services
    Service definitionMedical services provided to minors under state-specified conditions
    Parental consentServices may be provided without the consent of a parent or guardian
    California legal basis
    Policy Summary
    PayerPHC California
    PolicyAccess to Self-Referred Covered Services
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMarch 1, 2008
    Last ReviewOct 15, 2025
    Next Review DateN/A
    Key ActionProvide covered self-referred services without prior authorization or a provider referral, subject to stated limits and exceptions.
    SourceLink
    On This Page
    Covered Self-Referred Services and ExceptionsService Limits and Cost-Sharing RulesOperational Requirements for ProvidersKey Service Definitions

    For community providers other than the Local Health Department, the limit applies when immediate diagnosis and treatment are clinically indicated and within the general standard of care.

  1. American Indian enrollees receiving an item or service directly from an IHCP or through a referral to an IHCP are not subject to enrollment fees, premiums, deductibles, copayments, cost sharing, or similar charges.
  2. Emergency room medical care and follow-up treatment after rape or sexual assault are provided without cost sharing for the first nine months after treatment is initiated.No cost sharing for the first 9 months after treatment begins

    Care must not be conditioned on filing a police report, bringing criminal charges, or obtaining a conviction.

    3. Standard of careServices must be within the general standard of care
    Rape or sexual assault treatment cost-sharing protection
    Protected servicesEmergency room medical care and follow-up treatment for enrollees treated following rape or sexual assault
    Cost-sharing periodNo cost sharing applies for the first nine months after the enrollee initiates treatment
    Legal-action requirementCare is provided without requiring a police report, criminal charges, or an assailant conviction
    • Maximum without authorization: two chiropractic services per calendar month
    • Obtain authorization for services above the two-visit monthly limit
    Prior Authorization

    Process pregnancy termination authorization correctly

    Do not require medical justification or prior authorization for covered physician-performed pregnancy termination. If the termination requires non-emergency inpatient hospitalization, request admission authorization for review under acute inpatient criteria.

    • Pregnancy termination is a covered benefit when provided in accordance with applicable requirements
    • Non-emergency inpatient hospitalization requires prior authorization
    Prior Authorization

    Allow American Indian IHCP access

    Permit an American Indian enrollee to obtain covered services from an out-of-network IHCP, including an IHCP outside the service area, without a network PCP referral or prior authorization. Out-of-network IHCPs may refer directly to network providers under the same protections.

    • Access remains available even if an in-network IHCP becomes available
    • Do not impose enrollment fees, premiums, deductibles, copayments, cost sharing, or similar charges for services received directly from or through an IHCP
    Prior Authorization

    Preserve family planning provider choice

    Do not restrict an enrollee’s choice of a qualified family planning provider. Qualified out-of-network family planning providers may provide covered family planning services without prior authorization.

    • Permitted services include contraceptive counseling, methods, supplies, pregnancy testing and counseling, sterilization, and related medically indicated services
    • Out-of-network family planning providers may provide STI and HIV-related services within the policy’s scope
    Prior Authorization

    Permit out-of-network STI access

    Allow STI diagnosis and treatment through out-of-network local health departments, family planning clinics, and community STI service providers when the service is within the policy’s scope and immediate diagnosis and treatment are clinically indicated.

    • For community providers other than the Local Health Department, limit access to one visit per STI episode
    • Apply the Health Plan’s STI treatment policies and current CDC STI Treatment Guidelines
    Prior Authorization

    Permit out-of-network preventive and HIV services

    Allow confidential HIV testing and counseling through eligible out-of-network providers, including local health departments and family planning providers. Enrollees may also access local health departments for immunizations.

    • Maintain confidentiality for HIV testing and counseling services
    • Provide services according to the Health Plan’s HIV testing and counseling policies and applicable current CDC recommendations
    Denial Risk

    Do not condition assault care on legal action

    Provide emergency room medical care and follow-up treatment after rape or sexual assault without requiring a police report, criminal charges, or conviction. Do not impose cost sharing during the first nine months after treatment is initiated.

    • Do not condition treatment on legal action against the assailant
    • Apply the applicable no-cost-sharing protection for the first nine months after treatment begins
    Billing Rule

    Apply provider reimbursement rules

    Process all claims related to self-referred services in accordance with PHC California Policy and Procedure CL 14, Provider Reimbursement.

    • Apply CL 14 requirements when adjudicating claims for the services covered by this policy
    Documentation Required

    Document consent for sensitive services

    Obtain informed consent for all contraceptive methods, including sterilization, consistent with Title 22, California Code of Regulations, Sections 51305.1 and 51305.3. If a minor were enrolled, follow California minor consent and confidentiality requirements for qualifying services.

    • Document informed consent for contraceptive methods and sterilization
    • Apply California Family Code Sections 6920–6929 and applicable California minor consent and confidentiality laws for qualifying minor consent services
    California Family Code, Sections 6920–6929
    Family planning services
    Eligible enrolleesServices provided to enrollees of childbearing age
    Family planning purposeEnable enrollees to determine the number and spacing of their children
    Health purposeHelp reduce maternal and fetal deaths and diseases by promoting the health and education of potential parents