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.
- Abortion services may be obtained from any qualified in-network or out-of-network provider.
- Family planning, sexually transmitted infection (STI) diagnosis and treatment, HIV testing and counseling, and sexual assault services may be obtained from any qualified in-network or out-of-network provider. .
- 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.
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.
- MAO 638 Indial 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)
- Pregnancy 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).
- 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)
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. PPGs may not impose prior authorization requirements that conflict with the member's right to self-refer for services. 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.