Medi-Cal

Prior Authorization

Requesting pre-approval for special medical services

For some types of care, your doctor or specialist will need to ask your health network or CalOptima for permission before you get care. This is called asking for prior authorization, prior approval, or pre-approval. It means that your health network or CalOptima must make sure that the care is medically necessary or needed.

Care is medically necessary if it is reasonable and necessary to protect your life, keeps you from becoming seriously ill or disabled, or relieves severe pain.

The following services always need pre-approval, even if you receive them from a provider in your health network or in the CalOptima network:

  • Hospitalization
  • Services out of the CalOptima service area
  • Outpatient surgery
  • Long-term care at nursing facility
  • Specialized treatments

You never need pre-approval for emergency care, even if it is out of network. This includes having a baby.

If you would like to request a prior authorization, please contact your primary care provider (PCP) or specialist.

Below are a list of procedure codes that require prior authorization by your provider:

2019 Procedure Codes

October 2019 Download PDF Icon List of procedures that require prior authorization, effective 10/01/2019.

July-September 2019 Download PDF Icon List of procedures that require prior authorization, effective 07/01/2019-09/30/2019.

April-June 2019 Download PDF Icon List of procedures that require prior authorization, effective 04/01/2019-06/30/2019.

January–March 2019 Download PDF Icon List of procedures that require prior authorization, effective 01/01/2019–03/31/2019.

2018 Procedure Codes

October 2018 Download PDF Icon List of procedures that require prior authorization, effective 10/01/2018-12/31/2018.

July–September 2018 Download PDF Icon List of procedures that require prior authorization, effective 07/01/2018–09/30/2018.

April–June 2018 Download PDF Icon List of procedures that require prior authorization, effective 04/01/2018–06/30/2018.

January–March 2018 Download PDF Icon List of procedures that require prior authorization, effective 01/01/2018–03/31/2018.

2017 Procedure Codes

October–December 2017 Download PDF Icon List of procedures that require prior authorization, effective 10/01/2017–12/31/2017.

July–September 2017 Download PDF Icon List of procedures that require prior authorization, effective 07/01/2017–09/30/2017.

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