Prior Authorization
Please note, failure to obtain authorization may result in administrative claim denials. California Health & Wellness providers are contractually prohibited from holding any member financially liable for any service administratively denied by California Health & Wellness for the failure of the provider to obtain timely authorization.
Check to see if a pre-authorization is necessary by using our pre-authorization online tool.
Expand the links below to find out more information.
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
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:
|
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:
|
| Joint surgeries | |
Laboratory services:
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| 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:
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| 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.
|
| Uvulopalatopharyngoplasty (UPPP) and laser assisted UPPP | |
| Ventriculectomy, cardiomyoplasty | |
| Vestibuloplasty | |
| Wound care | Includes but not limited to:
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| Non-Benefit Services | Prior Authorization - California |
|---|---|
Community Supports
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Refer to CalAIM Resources for Providers |