20-092 Prior Authorization Requirements
Date: 01/24/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Additions and changes, effective April 1, 2020
See below for prior authorization (PA) requirement changes for Medi-Cal fee-for-service (FFS) providers. “New” indicates new requirement and “Existing” indicates current requirement.
Requirement | Comments | Adult members ages 21 and over | Pediatric members under age 21 |
Continuous glucose monitoring | Listed under Durable Medical Equipment (DME) | New benefit | Existing benefit under CCS.1 All DME requires prior authorization. |
H. pylori (Helicobacter pylori), antibody testing | Listed under Outpatient Procedures | New | |
Transplant | Listed under Outpatient Procedures | Removed HLA typing | |
Added Transplants must be performed through Health Net’s designated transplantation specialty network | |||
Aliqopa™, azedra®, Beouvu®, Besponsa®, Folotyn®, Kanuma®, Lutathera®, Polivy™ | Listed under Outpatient Pharmaceuticals | New | |
1CCS – California Children’s Services
View authorization requirements online
Follow the steps below to find out if prior authorization is needed for any procedures, services or equipment:
1 Go to provider.healthnet.com.
2 Before logging in, select Working with Health Net > Policies for Non-Contracting Providers > Additional Resources > Services Requiring Prior Authorization.
3 After logging in, select Working with Health Net > Contractual > Services Requiring Prior Authorization.
If you have questions regarding the information contained in this update, contact
CalViva Health at 1-888-893-1569.