25-324sum Summary Update: Updates to the Prior Authorization Process, and New and Upcoming Requirements Changes
Date: 04/11/25
Stay aligned with available options for submitting prior authorization requests; discover what’s changed or will change for procedures, services and drugs
Refer to the complete update, 25-324, Updates to the Prior Authorization Process, and New and Upcoming Requirements Changes (PDF), for prior authorization updates detailed below.
Use any of three options for submitting prior authorization requests
Physicians and other providers can submit requests for prior authorization via any of following:
- Fax – Complete the appropriate CalViva Health Inpatient or Outpatient Prior Authorization Request form, and fax to 800-743-1655. Forms are available at Prior Authorizations.
- Online – Log on to the secure provider portal.
- Phone – Call Provider Services at 888-893-1569. Behavioral health providers may contact 844-966-0298.
Key prior authorization requirement changes include:
- New CPT and HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS) that require prior authorization as of January 1, 2025.
- Additions, effective immediately, on April 1 or on June 15, 2025.
- Additional procedures, services (including durable medical equipment and outpatient pharmaceuticals) that require prior authorization as of April 1, 2025, per new CPT and HCPCS codes issues by CMS, will be communicated in a forthcoming provider update.
- Changes, effective immediately.
- Removals, effective June 15, 2025.
How to access prior authorization requirements
Use either option below to access the Medi-Cal Prior Authorization Requirements:
- Go to the Provider Library, select Medi-Cal, then select Prior Authorization Requirements on the left side.
- Go to Prior Authorizations and select the Fresno, Kings and Madera counties – CalViva Health Prior Authorization List.
Additional information
Relevant sections of the provider operations manuals have been 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.
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, and Behavioral Health Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.