23-364sum Summary Update: Know What Changes are Coming for Prior Authorizations
Date: 04/26/23
Drugs that require prior authorization now and more changes that start July 1, 2023
The complete update to the prior authorization (PA) changes for Commercial (HMO/POS/HSP, EPO, PPO) and Medi-Cal fee-for-service providers is found on 23-364, Know What Changes are Coming for Prior Authorizations (PDF).
Key Changes | |
|---|---|
Requirement | Comments |
Incontinence supplies | Medi-Cal members under age 21 – the Plan will discontinue reviewing requests from participating providers for incontinence supplies effective July 1, 2023. - California Children’s Services (CCS) eligible diagnosis should be confirmed and related services directed to CCS. - For more information about the CCS member verification process go to the Department of Health Care Services (DHCS) Medical Authorizations and Claims. - We continue to follow Medi-Cal requirements regarding quantity limits. For additional information refer to the Quantity Limits outlined in the List of Incontinence Medical Supply Billing Codes (incont billing). |
Outpatient pharmaceuticals (medical benefit medications) | - New outpatient pharmaceuticals (medical benefit medications) requiring authorization per the new HCPCS issued by the Centers for Medicare and Medicaid Services (CMS) effective January 1, 2023 and April 1, 2023. - Additions, changes and deletions, effective July 1, 2023, to outpatient pharmaceuticals. |
Sleep studies | Medi-Cal fee for service members only: Home-based sleep testing no longer requires PA effective July 1, 2023. (Facility sleep testing continues to require PA.) |
Use the new Coram contact information
Coram is the Plan’s preferred infusion provider. Effective immediately, Coram can be contacted at the following numbers:
- Phone: 866-899-1661
- Fax: 866-843-3221
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.