Prior Authorization Requirements

California
Medi-Cal

Effective July 1, 2023

The services, procedures, equipment and outpatient pharmaceuticals below apply to Health Net and CalViva Health Medi-Cal fee-for-service (FFS) members in the following counties:

These are subject to prior authorization (PA) requirements (unless noted as "notification" required only) if an “X” is included under the applicable age group. If “X” is not present, PA may not be required or the service, procedure, equipment or outpatient pharmaceutical may not be a covered benefit. PA is guaranteed only as of the time of access to this prior authorization requirements page. Providers are responsible for verifying member eligibility through the Medi-Cal Provider Services Center prior to providing care. Even if a service or supply is authorized, eligibility rules and benefit limitations will still apply.

This PA list is not intended to be a list of covered services. The member’s Evidence of Coverage (EOC) provides a complete list of covered services. EOCs are available on the Medi-Cal member page under Medi-Cal Member Handbooks. PA limitations and exclusions, in addition to sensitive, confidential or other services that do not require PA for Medi-Cal members, are provided below. 

Submit a prior authorization request to Health Net unless stated differently in requirements listed below. Requests should be submitted to Health Net via fax. The Health Net Request for Prior Authorization form must be completed in its entirety and include sufficient clinical information or notes to support medical necessity for services that are requested.

When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. All services, procedures, equipment, and outpatient pharmaceuticals are subject to benefit plan coverage limitations; members must be eligible; and medical necessity must exist for any plan benefit to be a covered service irrespective of whether or not PA is required.

If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.