25-1000 Streamlining Prior Authorization: Simplifying Processes for Better Efficiency
Date: 09/24/25
New code updates to minimize administrative burden and enhance patient care
In our continuous effort to improve the prior authorization (PA) experience for both providers and members, we are implementing significant updates to our PA requirements. These changes align with industry-wide modernization initiatives and commitments to regulatory agencies and AHIP, striving to make prior authorization more efficient and transparent.
What’s changing?
Starting December 1, 2025, updated PA code requirements will take effect, as detailed in the table below.
Key changes include:
- Removal of certain PA requirements based on clinical necessity and review urgency.
- Standardization of PA requirements across lines of businesses to reduce confusion and support future real-time authorization capabilities.
Our objectives:
- Reduce administrative burden.
- Simplify submission and approval processes.
- Support timely access to high-quality, medically necessary care.
Accessing PA requirements
Access the Medicare PA requirements via either option below:
- Go to the Provider Library > Medicare Advantage > Prior Authorization Requirements (on the left side).
- Go to Prior Authorizations and select the Medicare - California Prior Authorization List.
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Service category | PA rule | Services | Codes |
|
|---|---|---|---|---|
Ambulance | PA required | Non-emergency air transportation | A0431, A0436 |
|
Durable medical | No PA required | Equipment accessories | E0953, K0019, K0044, K0045, K0047, K0051, K0052 |
|
Mattress | E0184 |
| ||
Nerve stimulators | E0720, E0730 |
| ||
Wheelchairs | E0954, E0956, E0957, E0973, E0990, E1016, E1028, E2209, E2210, E2359, E2361, E2363, E2365, E2367, E2603, E2604, E2606, E2607, E2615, E2616, E2624, K0043, K0077, K0733 |
| ||
Home health services | No PA required | Home management | G0156 |
|
Prosthetics | No PA required | Addition to lower extremity prosthesis | L5926, L5617 | |
Sleep medicine | No PA required | Sleep studies | 95805 |
|
Surgery procedures | PA required | Hysterectomies | 58571 |
|
No PA required | Treatment of varicose veins | 36471, 37765, 37766 |
| |
Skin substitutes & wound dressings
| PA required | Skin substitutes & wound dressings | C9358, C9360, C9363, Q4111, Q4115, Q4117, Q4118, Q4125, Q4134, Q4135, Q4136, Q4139, Q4145, Q4162, Q4165, Q4166, Q4167, Q4168, Q4170, Q4171, Q4174, Q4176, Q4177, Q4179, Q4180, Q4181, Q4182, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4214, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246, Q4247, Q4248, Q4251,Q4252, Q4253 |
|
Therapy | No PA required | Physical, occupational and speech therapy exceeding 12 visits | 97010, 97012, 97024, 97033, 97035, 97150, 97542, G0283 |
|
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
Behavioral health providers can call 844-966-0298.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary, and Behavioral Health Providers.