All attempts are made to provide the most current information on the Pre-Auth Needed Tool. A prior authorization is not a guarantee of payment. Payment may be denied in accordance with Plan’s policies and procedures and applicable law. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
To submit a medical prior authorization, Login Here.
To submit a medication prior authorization, use the
Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211) (PDF).
Vision services need to be verified by Envolve Vision Care
Dental services need to be verified by Medi-Cal
Chiropractic Services need to be verified by Medi-Cal
Complex imaging, MRA, MRI, PET, and CT Scans need to be verified by NIA
Substance Abuse and Inpatient Behavioral Health Services need to be verified by Medi-Cal
Outpatient Behavioral Health Services, please contact the Health Plan for Pre-authorization information
CCS member process verification, click here
Non-participating providers must submit Prior Authorization (Inpatient Form (PDF), Outpatient Form (PDF)) for all services except those performed in the Emergency Department, Urgent Care, or "Sensitive Services" as noted below.
For non-participating providers, Join Our Network
For Enteral Nutrition, please visit our Enteral Nutrition page.
The California Health and Wellness prior authorization coding edits communicated to providers effective 01/01/2019 are not fully loaded. Please submit prior authorization if indicated once reviewed below
CCIPA Providers Please Note:
- CCIPA is responsible for all Prior Authorization of provider-administered medications except for chemotherapy (including adjunctive therapy) and transplant immunosuppression.
- California Health & Wellness is responsible for prior authorization of ALL provider-administered medications for chemotherapy (including adjunctive therapy) and transplant immunosuppression.
- Please see the injectable medication HCPS/DOFR Crosswalk (PDF) to determine provider-administered “therapeutic” vs. self-administered injectables.
Please route Prior Authorization requests accordingly, using the use the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211) (PDF).
Are services being performed in the Emergency Department, (location 23), or Urgent Care, (location 20), or “Sensitive Services” related to sexual assault, substance/alcohol abuse, pregnancy, family planning, sexually transmitted diseases, HIV testing and abortion?
|Types of Services||YES||NO|
|Is the member being admitted to an inpatient facility?|
|Is the member receiving inpatient hospice services?|
|Are anesthesia services being rendered for pain management or dental surgeries?|
|Are plastic or oral surgeon services being rendered in the office?|
|Are services for transgender surgery or other procedures?|
|Does the member have a CCS diagnosis?|
To submit a medication prior authorization, use the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211) (PDF).