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 and 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
- Federal Indian Health Service providers identified as MOA 638 facilities do not require prior authorization approval for certain services.
- Musculoskeletal Services need to be verified by TurningPoint. Please contact TurningPoint at 1-855-332-5898 or fax at 1-949-774-2254.
Non-participating providers (excluding MOA 638 Indian Health Service facilities) 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.
For members under age 21, authorization is required for testing and in-office procedures performed by pediatric sub-specialists, including, but not limited to:
- Otolaryngologists (ear, nose, throat)
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?|
|Is the member under age 21 AND are services being performed by a pediatric cardiology, dermatology, endocrinology, gastroenterology, genetics, nephrology, neurology, ophthalmology, orthopedics, otolaryngology (ear, nose, and throat), podiatry, pulmonology, or urology subspecialist?|
To submit a medication prior authorization, use the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211) (PDF).