24-1320 Action Needed: Request Prior Authorization for NEMT and Submit PCS Forms Directly to Health Net for Medi-Cal Members
Date: 12/23/24
Avoid delays in member care by faxing a signed PCS form to Health Net Care Ride Unit, not Modivcare.
Health Net and its delegated entities must provide medically necessary non-emergency medical transportation (NEMT) services when a member's medical or physical condition prevents them from using regular public or private transportation, and such transportation is essential for accessing medically necessary services.
NEMT includes ambulances, wheelchair vans and gurney vans. It is provided when medically necessary and the patient is not ambulatory, or is unable to stand or walk without assistance, including if using a walker, cane or crutches. This includes all door-to-door assistance transports.
What’s changing
First, starting March 1, 2025, Medi-Cal members will experience a change in the way they request transportation services. Instead of contacting Modivcare, members must now reach out directly to their physician or other relevant provider to arrange transportation services.
Second, starting March 1, 2025, NEMT requires prior authorization from Health Net’s Care Ride Unit.
What you must do
Starting March 1, 2025, physicians and other providers must take the following steps to ensure Medi-Cal members can access and utilize their transportation benefits:
- Let CalViva Health Medi-Cal members know they must contact their physician or other provider if they need medical transportation.
- Fill out and sign the Physician Certification Statement (PCS) form for the member when the member requests medical transportation.
- Fax the completed, signed PCS form to the Plan at 833-701-0051 to request prior authorization. Do not send it to Modivcare.
Refer to the chart below to see a summary of the current and new processes as of March 1, 2025.
Question | Current process | New process as of March 1, 2025 |
|---|---|---|
Who initiates request? | The member contacts Modivcare regarding transportation needs. | The member will reach out to the physician or other provider to request medical transportation. |
What happens | Modivcare faxes the PCS form to the physician or other provider, who completes the form and sends it back to Modivcare. | The physician or other provider sends the completed PCS form to Health Net to request prior authorization. Health Net will notify the physician or other provider and member of the authorization decision, and will notify Modivcare daily of approved authorizations. The member will contact Modivcare to coordinate scheduling. |
Download the PCS form online
For the most up-to-date PCS form, we recommend downloading it directly from Health Net's Provider Library > Medi-Cal > Forms and References > Physician Certification Statement Form - Request for Transportation CalViva Health. New forms will be available on March 1, 2025. Here’s how you can access the Provider Library:
Option 1 – Log in on the provider portal
- Log in at provider portal.
- Select Provider Library under Quick Links.
Option 2 – Go directly to the Provider Library.
Prior authorization request forms are available at provider website > Providers > Provider Support > Working with Health Net > Additional Resources > Services Requiring Prior Authorization.
Additional information
Relevant sections of the provider operations manuals and the Behavioral Health Provider Operations Manual will be revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on the provider portal.
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569. Behavioral Health providers can call at 844-966-0298.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.