Services Not Requiring Prior Authorization
Provider Type
- Physicians
- 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.
- Adult sensitive care services:
- Family planning and birth control including sterilization for adults 21 and older.
- Pregnancy testing and counseling and other pregnancy related services.
- HIV/AIDS prevention and testing.
- Sexually transmitted infections prevention testing.
- Sexual assault care.
- Outpatient abortion services.
- Drug and alcohol abuse treatment and mental health treatment - these services are not covered by Health Net's Medi-Cal managed care plan and may be obtained through the county drug and alcohol program and the county mental health program.
Referral and prior authorization are not required for Comprehensive Prenatal Services Program (CPSP) services. Services may be obtained from any participating CPSP providers.
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:
- 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 the Plan’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)
- Basic prenatal care with a participating in-network obstetrician.
- Preventive services from a participating provider.
- Services for emergency medical conditions.
- Specialist referral (initial referral to participating specialist).
- Second opinion from a participating physician or other provider
- Urgently needed services when the member is outside their county
- Certified nurse midwife and 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 FDA-approved)
- COVID-19 diagnostic and screening testing
- Services that are rendered under the Children and Youth Behavioral Health Initiative fee schedule
- Initial mental health and substance use disorder assessments
- Adult preventive immunizations from a participating physician or other provider
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.