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
- Family planning services
- Sexual assault services
- Age 12 and older - under 21
- Pregnancy and pregnancy related services
- Family planning services
- Sexual assault services
- Infectious, contagious, or communicable disease diagnosis and treatment
- Sexually transmitted diseases (or infections) prevention, diagnosis, and treatment
- Drug and alcohol abuse treatment and counseling
- Outpatient mental health treatment and counseling. Minors may obtain outpatient mental 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
- 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 and treatment
- Sexual assault care
- Outpatient abortion services
- In-network outpatient therapy and medication management services for mild to moderate distress due a mental health disorder.
- Refer to the CPSP for more information about locating a CPSP provider.
Note: Specialty mental health services and select substance use disorder services are covered by the county mental health program. If coordination assistance with the county mental health program 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.
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:
- Outpatient Hospice Service:
- Outpatient hospice services: Prior Authorization is not required for routine home care, continuous home care and respite care, or hospice physician services provided by in-network hospice providers. Submit all required documentation (see below) via encrypted email.
Required documentation:
- Certification of the patient’s terminal illness;
- Medi-Cal Hospice Program Election form (PDF);
- Revocation of hospice election, documenting the patient’s decision to discontinue hospice care;
- Copy of the written initial plan of care;
- Written prescription signed by the patient’s attending physician, which includes justification for general inpatient level of care;
- Face-to-face encounter document that verifies clinical evaluation for continued eligibility; and
- Transfer summary when the patient changes health plan carriers.
Refer to APL 25-008 for additional information
- 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.
- California Prenatal Screening (PNS)
- Services for emergency medical conditions.
- Not applicable to 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
- 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 by a participating provider
- 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 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.