Services Not Requiring Prior Authorization
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Prior authorization is not required for the following services, and services may be obtained from any qualified in-network or out-of-network provider:
- Emergency services.
- Minor consent services which include treatment for the following:
- Under age 12
- Pregnancy and pregnancy-related services, including abortion services
- Family planning services, such as contraception services (e.g., birth control)
- Sexual assault services
- Ages 12 and older - under age 18
- Pregnancy and pregnancy-related services, including abortion services
- Family planning services, such as contraception services (e.g., birth control)
- Sexual assault services
- Infectious, contagious, or communicable disease diagnosis and treatment, including for HIV/AIDS
- Sexually transmitted infection (STI) prevention, testing, diagnosis, and treatment for STIs like syphilis, gonorrhea, chlamydia, and herpes simplex
- Substance use disorder treatment for drug and alcohol abuse treatment and counseling
- Outpatient behavioral health treatment and counseling. Minors may obtain outpatient behavioral health services, if in the opinion of the attending professional person determines that the minor is mature enough to participate intelligently in their health care pursuant to Family Code section 6924.
- Intimate partner violence
- Under age 12
- Adult sensitive care services:
- Family planning and birth control including sterilization for adults ages 21 and older
- Pregnancy testing and counseling and other pregnancy-related services
- HIV/AIDS prevention and testing
- Sexually transmitted infections prevention testing and treatment
- Sexual assault care
- Outpatient abortion services
- In-network outpatient therapy and medication management services for mild to moderate behavioral health conditions. Out-of-network services require prior authorization.
- Note: Specialty behavioral health services and select substance use disorder services are covered by the County Mental Health Plan. If coordination assistance with the County Mental Health Plan is needed, contact Medi-Cal Member Services (Medi-Cal, CalViva Health, CHPIV).
- Referral and prior authorization are not required for Comprehensive Prenatal Services Program (CPSP) services. Services may be obtained from any participating CPSP providers. Refer to the CPSP for more information about locating a CPSP provider.
- A member or provider is not required to obtain prior authorization for Non-Emergency Medical Transportation (NEMT) services if the member is being transferred from an emergency room to an inpatient setting, or from an acute care hospital, immediately following an inpatient stay at the acute level of care, to a skilled nursing facility, an intermediate care facility or embedded psychiatric units, free standing psychiatric inpatient hospitals, psychiatric health facilities, or any other appropriate inpatient acute psychiatric facilities.
Other services that do not require prior authorization include:
- Hospice room and board for members receiving hospice services and residing in a skilled nursing facility (SNF)/nursing facility or intermediate care facility (ICF). Certain documents are still required to be submitted to the Health Net. For additional details, refer to the Hospice Services Documentation Guide Health Net (PDF), CalViva Health (PDF), Community Health Plan of Imperial Valley (PDF).
- Certain services for American Indian members, including:
- An American Indian member can obtain covered services from an out-of-network Indian health care provider without requiring a referral from a network primary care provider (PCP) or prior authorization.
- MOA 638 Indian Health Services facilities or provider, whether in Health Net's network or out-of-network, can provide referrals directly to network providers without a referral from a network PCP or prior authorization. An American Indian member may receive services from an out-of-network Indian health care provider even if there are in-network Indian health care providers available.
- Department of Health Care Services (DHCS)-required immunizations when provided from the local health department (LHD) (LHD must submit immunization records with any claim).
- Adult preventive immunizations from a participating provider.
- Basic prenatal maternal and preventive services and care as defined by the most current clinical standards or guidelines of American College of Obstetricians and Gynecologists (ACOG) and Comprehensive Perinatal Services Program (CPSP) with a participating network obstetrician
- Preventive services from a participating provider.
- California Prenatal Screening (PNS) services performed by participating providers.
- California Newborn Screening Program administered by California Department of Public Health (CDHP) up to one year of age.
- Certified Nurse Midwife (CNM) or Licensed Midwife (LM) coverage of basic prenatal, maternal, and preventive services and care (ACOG/CPSP) in and out of network.
- Lactation consultation for pregnant and postpartum members.
- Breast pumps: non-hospital grade (manual and electric) from participating providers.
- Outpatient abortion services (in or out of network).
- Not applicable to participating physician groups (PPGs) - Specialist referral (initial referral to participating specialist).
- Not applicable to PPGs - Second opinion from a participating physician or other provider.
- Urgently needed services when the member is outside their county.
- Obstetrical/gynecological (OB/GYN) services from a participating provider.
- Biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer (must be U.S. Food & Drug Administration-approved).
- COVID-19 diagnostic and screening testing.
- Services that are rendered under the Children and Youth Behavioral Health Initiative fee schedule.
- Initial behavioral health and substance use disorder assessments
- In-network outpatient therapy and medication management services for mild to moderate behavioral health conditions. Out-of-network services require prior authorization.
- Note: Specialty behavioral health services and select substance use disorder services are covered by the County Mental Health Plan. If coordination assistance with the County Mental Health Plan is needed, contact Medi-Cal Member Services (Medi-Cal, CalViva Health, CHPIV).
Health Net has delegated the prior authorization process to some participating physician groups (PPGs). Prior authorizations for members assigned to a capitated PPG are subject to any additional rules imposed by the PPG. Refer to the PPG for authorization requirements. PPGs may not impose prior authorization requirements that conflict with the member's right to self-refer for certain services.