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 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 Request Form (No. 61-211).

You may fax requests to:

Inpatient Authorizations 1-866-724-5057 Form
Outpatient Medical Services 1-866-724-5057 Form
Concurrent Reviews – Clinicals 1-855-556-7910 Form
Admissions / Face Sheets / Census Reports 1-855-556-7907  
Behavioral Health Services 1-866-694-3649*  
CBAS Treatment Requests 1-855-556-7909 Form
Self-Administered Non-Specialty Medications 1-866-399-0929 Form
Self-Administered Specialty Medications 1-855-217-0926 Form
Physician-Administered Specialty Medications 1-877-259-6961 Form

*Fax form coming soon

Or login to submit a prior authorization

High Tech Imaging Services (CT, MRI, PET) are authorized by National Imaging Associates at www.radmd.com

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 and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

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: 1-877-658-0305
Fax requests to: 1-866-724-5057

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

Service PA - California
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 For members under the age of 21 years
Bariatric surgery  
Community Based Adult Services (CBAS)   
Cosmetic surgery   
DME  - including but not limited to: medical supplies, wound vacs, customized equipment, orthotics and prosthetics Certain procedure codes; call or go to CHW website to determine if authorization is required
All inpatient hospitalizations (notification at least 5 business days prior to the scheduled date of admit)  
Emergency Admissions and/or Observation Stay (notification within 1 business day of admission)  
Enteral Nutrition Products  
Experimental or investigational treatments/services; clinical trials  
General anesthesia for dental services  
Hearing Aid Devices/Cochlear Implants  
Home Health Services, including nursing, infusion  and supplies   
Hospice   
Implantable devices   

Laboratory Services:

  • Genetic /Molecular Diagnostic Testing
  • Quantitative Drug Screening
 
Nursing Facility Admissions (Skilled Nursing Facility)   
NICU   
Mental Health Services such as psychological testing and neuro-psychological testing for individuals with mild to moderate treatment needs require prior authorization. Following a PCP's EPSDT screening, Behavioral Health Treatment for members with an Autism Spectrum Disorder diagnosis require prior authorization.
Out of Network Providers and Services

All inpatient and outpatient physical health services rendered by Out of Network Providers require prior authorization.

All outpatient behavioral health services rendered by Out of Network Providers require prior authorization.

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
Pain Management Services  
Radiology Imaging-CT, MRA, MRI, PET   

Go to www.radmd.com

Rehabilitation - Inpatient  

Pharmacy Services 

See PDL on CH&W 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.  
Specialist Consultation and/or procedures For members under the age of 21 years
Specialty and Bio-Pharmaceutical Therapy See CH&W Provider Website “Pharmacy Program” page for Specialty Pharmacy PA Information and “Pre-Auth?” page for checking PA status of provider administered drugs.
See CH&W Provider Website “Pharmacy Program” page for Specialty Pharmacy PA Information and “Pre-Auth?” page for checking PA status of provider administered drugs.  
Transplant Services including Evaluation    
Transportation - Non-Emergency (fixed wing air transport)