25-327sum 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, 25-327, 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 the following:
Line of business | Fax | Online | Phone |
|---|---|---|---|
IFP Ambetter HMO | 844-694-9165 |
|
Behavioral health: 844-966-0298 |
IFP Ambetter PPO
| 844-694-9165 |
|
Behavioral health: 844-966-0298 |
Employer group HMO/POS, PPO | 844-694-9165 |
|
Behavioral health: 844-966-0298 |
Medi-Cal | 800-743-1655 |
|
Behavioral health: 844-966-0298 |
The Commercial and Medi-Cal Inpatient and Outpatient Prior Request forms are available at Prior Authorizations.
Key prior authorization requirements 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 and changes, effective immediately, on April 1 or on June 15, 2025.
- Additional procedures, services (including durable medical equipment and outpatient pharmaceuticals) that require PA 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 a line of business, then select Prior Authorization Requirements on the left side.
- Go to Prior Authorizations and select the Commercial - California or Medi-Cal Fee-for-Service Prior Authorization List.
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 Providers, and Behavioral Health Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.