25-998 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 requirements1. 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 tables 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 PA requirements via either option below:
- Go to the Provider Library > select a line of business > Prior Authorization Requirements (on the left side).
- Go to Prior Authorizations and select the Medi-Cal Fee-for-Service Health Net or the Commercial – California Prior Authorization List.
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Commercial
Service category | PA rule | Services | Codes |
|---|---|---|---|
Behavioral health | PA required | Partial hospital program (PHP) full or half day | H0035
|
Intensive outpatient program (IOP) | S9480 | ||
Transcranial magnetic stimulation (TMS) | 90867, 90868 | ||
No PA required | Applied behavioral analysis (ABA) | 97157 | |
Outpatient | PA required | Thyrogen® | J3240 |
Feraheme® | Q0138, Q0139 | ||
Laboratory | PA required | Pathology | 88377 |
Therapy | No PA required | Physical therapy | 97010 |
Surgery procedures | PA required | Cardiovascular procedure | 37243 |
Digestive system | 43281, 49329 | ||
Male genitalia | 55866 | ||
Musculoskeletal system | 28300, 28308, 28285, 28299 | ||
No PA required | Facial, cranial and TMJ procedures | 21230 | |
Dermatology – skin injections | 11900, 11901 | ||
Treatment of varicose veins | 36476 | ||
Wound care | 13100, 13101, 13102, 13120, 13121, 13122 |
Medi-Cal
Service category | PA rule | Services | Codes |
|---|---|---|---|
Behavioral health | PA required | Transcranial magnetic stimulation (TMS) | 90867, 90868 |
Durable medical | PA required | Incontinence supplies | T4521, T4522, T4523, T4524 |
Continuous glucose monitoring | A4239 | ||
No PA required | Oxygen | E0441 | |
Outpatient pharmaceuticals | PA required | Thyrogen® | J3420 |
Aristada® | J1944 | ||
Paliperidone palmitate | J2426, J2427 | ||
Genetic analysis | No PA required | Genetic Testing | 81244, 81331 |
Home services | No PA required | Applied behavioral analysis | S5111 |
Enteral nutrition products | S9342, S9343 | ||
Community supports | No PA required | Respite services | S9125 |
Wound care | No PA required | Skin grafts | 15240, 15241, 15260, 15261, 15272, 15777 |
Surgery procedures
|
PA required
| Cardiovascular procedure | 37243 |
Hernia repair | 49591, 49593, 49595, 49650 | ||
Nervous system | 64999 | ||
No PA required | Elective surgery for members ages 0-20 | 69705, 69706 | |
Dermatology – skin injections | 11900, 11901 | ||
Treatment of varicose veins | 36471, 36479 | ||
Wound care | 13100, 13101, 13102, 13120, 13121, 13122, 13151, 13152 | ||
Transportation | PA required | Non-emergency medical transportation | A0428 |
1Note for CS and ECM Providers: Select prior authorization updates may not apply to Community Supports (CS) or Enhanced Care Management (ECM) services. Please contact your program liaison if you have questions about authorization requirements specific to your services.
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, Community Supports (CS) Providers, Enhanced Care Management (ECM) 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.