Prior Authorization

As the Medical Home, PCPs should coordinate all healthcare services for California Health & Wellness members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient's medical record.

Some services require prior authorization from California Health & Wellness in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

Medication prior authorization requests may be submitted by fax using the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211) – English (PDF).

You may fax requests to:

Service	Fax Number	Download form
Inpatient Authorizations	866-724-5057	Inpatient Medicaid Prior Authorization Fax Form – English (PDF)
Outpatient Medical Services	866-724-5057	Outpatient Medicaid Prior Authorization Fax Form – English (PDF)
Concurrent Reviews – Clinicals	855-556-7910	No download available
Admissions / Face Sheets / Census Reports	855-556-7907	No download available
CBAS Treatment Requests	855-556-7909	CBAS Treatment Request Form – English (PDF)
Long-term Care	866-724-5057	Long-Term Care Authorization Notification Form – English (PDF)
Non-Emergency Medical Transportation (NEMT)	Modivcare: 877-457-3352	Physician Certification Statement (PCS) – English (PDF)
Pharmacy or Self-Administered Medications	Medi-Cal RX 800-859-4325	Refer to the Medi-Cal Rx Contract drug list of covered drugs and services. Prior authorizations may be required, and providers may use Cover My Meds to submit a prior authorization request or complete a Prior Authorization Form at Medi-Cal RX Provider Portal
Physician-Administered Medications	877-259-6961	Prescription Drug Prior Authorization or Step Therapy Exception Request Form – English (PDF)
High Tech Imaging Services (CT, MRA, MRI, PET)	Log into RadMD	National Imaging Associates

*Fax form coming soon

Or log in to submit a prior authorization.

California Health & Wellness's Medical Management department hours of operation are 8 a.m. – 5 p.m. Monday through Friday (excluding holidays). After normal business hours, NurseWise staff is available to answer questions and intake requests for prior authorization.

• Emergent services do not require prior authorization.
• Urgent/emergent admissions require notification within one (1) business day following the admit date.
• For post-stabilization care:
  • Participating facilities do not require prior authorization.
  • Non-participating facilities do require prior authorization and should contact the Hospital Notification Unit at 877-658-0305.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

Prior Authorization List

Phone requests to: 877-658-0305

Fax requests to: 866-724-5057

To check if Prior Authorization is required for specific codes, go to our coding determination tool.

Service	Prior Authorization - California
All inpatient hospitalizations	Notification at least 5 business days prior to the scheduled date of admit All hospitalizations to nonparticipating hospital once emergency stabilization is complete
All members under age 21	California Children's Services (CCS) eligible diagnosis should be confirmed and related services directed to CCS. Providers can access PEDI to affirm active eligibility. If member has a CCS diagnosis but no open case with CCS, submit prior authorization requests to the Plan for all services other than well visits, preventive services, immunizations, emergency services, urgent care services, minor consent services (sexual assault, pregnancy care, family planning, sexually transmitted disease services), HIV testing, abortion.
Ablative techniques for treating Barrett's esophagus, and for treatment of primary and metastatic liver malignancies
Bariatric surgery
Bronchial thermoplasty
Capsule endoscopy
Cochlear implants
Community Based Adult Services (CBAS)	Prior authorization is required for greater than five visits per week CBAS services with one to five visits per week require notification only Fax authorization and notifications to 855-556-7909
Developmental screening	Prior authorization required for ages 6–20 (effective November 11, 2020)
Durable medical equipment (DME) - including but not limited to: Bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP) Bone growth stimulator Custom-made items including orthotics Hospital beds and mattresses Items with a total Medi-Cal purchase price greater than $1,500 Oxygen Power wheelchairs or scooters Prosthetics Ventilators	All DME for pediatric members requires prior authorization Certain procedure codes; call or go to CHW website to determine if authorization is required
Emergency admissions (notification within 1 business day of admission)
Enteral nutrition products
Experimental or investigational treatments/services; clinical trials
General anesthesia for dental services
H. pylori (Helicobacter pylori) antibody testing
Hospice	Inpatient hospice
Intensive outpatient cardiac rehabilitation (ICR) services	ICR services must be provided within an ICR program approved by the Centers for Medicare & Medicaid Services (CMS). Providers must include the following information when submitting a prior authorization request for ICR services: CMS-approved program the member is participating in Qualifying diagnosis Treatment plan Duration of services
Joint surgeries
Laboratory services: Genetic/molecular diagnostic testing Quantitative drug screening
Long term care nursing facility admissions	Fax Long-Term Care Authorization Notification (PDF) referral form to 866-724-5057
Lung volume reduction
Maze procedures
Mental health	Services such as psychological testing and neuropsychological testing for individuals with mild to moderate treatment needs require prior authorization. Following a PCP's EPSDT screening, behavioral health treatment for members require prior authorization.
Nursing facility admissions (skilled nursing facility)
Orthognathic procedures (includes TMJ treatment)
Out-of-network providers and services	Services rendered by out-of-network providers require prior authorization. Excludes emergency services and self-referral services allowed under the Medi-Cal plan for family planning, pregnancy termination, HIV counseling and testing, immunizations at the local health department, and sexually transmitted infections (STIs).
Outpatient surgeries and procedures performed in outpatient facilities or ambulatory surgery centers	Certain procedure codes; call or go to CHW website to determine if authorization is required
Outpatient therapies: physical, occupational and speech	Requires prior authorization after 12 combined visits. Includes home setting.
Pain management services
Pharmacy services	See PDL on CHW website for list of covered drugs and Limitation/Restrictions – notification within 1 business day of request receipt. The plan will cover the pharmacy to dispense a 72-hour emergency supply of an outpatient drug while awaiting a prior-authorization decision.
Radiology imaging - CT, MRA, MRI, PET	Go to the RadMD website.
Reconstructive and cosmetic surgery, services and supplies, including, but not limited to: Bone alteration or reshaping, such as osteoplasty Breast reduction and augmentation except when following a mastectomy (includes for gynecomastia or macromastia) Dermatology, such as chemical exfoliation and electrolysis, dermabrasions and chemical peels, laser treatment or skin injections and implants Excision, excessive skin and subcutaneous tissue (including lipectomy and panniculectomy) of the abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas. Eye or brow procedures, such as blepharoplasty, brow ptosis or canthoplasty Muscle flap Nasal surgery such as rhinoplasty or septoplasty Otoplasty Penile Implant Treatment of varicose veins
Rehabilitation - Inpatient
Sleep studies	Facility based sleep testing
Specialist consultation and/or procedures	For members under age 21
Specialty and bio-pharmaceutical therapy	See CHW provider website "Pharmacy" page for Specialty Pharmacy PA Information and "Pre-Auth Check" page for checking PA status of provider administered drugs.
Spinal surgery, includes, but not limited to, laminotomy, discectomy, vertebroplasty, nucleoplasty, and X- stop
Transplant services including evaluation	Fax requests to: 833-769-1140
Transportation	All non-emergency medical transportation (NEMT) requires a Physician Certification Statement (PCS) (PDF). Fax form to 877-457-3352. Air transportation (air ambulance), authorized by California Health & Wellness Ground NEMT, contact Modivcare (ambulance, gurney/stretcher, wheelchair)
Uvulopalatopharyngoplasty (UPPP) and laser assisted UPPP
Ventriculectomy, cardiomyoplasty
Vestibuloplasty
Wound care	Includes but not limited to: Negative pressure wound treatment, low-frequency ultrasound Skin substitutes and biologicals Wound debridement – authorization required after 12 sessions per year

Non-Benefit Services

Non-Benefit Services

Prior Authorization - California

Community Supports Asthma remediation Community transition services Day habilitation Environmental accessibility adaptations (home modifications) Housing deposits Housing tenancy and sustaining services Housing transition navigation services Meals/medically tailored meals Nursing facility transition/diversion to assisted living facilities, such as residential care facilities for elderly and adult residential facilities Personal care and homemaker services Recuperative care (medical respite) Respite services Short-term post-hospitalization housing Sobering centers

Refer to CalAIM Resources for Providers