Prior Authorization Requests
All elective services at tertiary level of care centers require prior authorization. Requests must include justification for tertiary level of care. Tertiary level of care is specialized care that is requested by a member’s primary care provider (PCP) or specialist physician.
Inpatient
- Scheduled inpatient admissions require prior authorization.
- All emergency admissions require notification within 24 hours.
- All post-stabilization services require authorization by the Utilization Management department.
Outpatient
Speech Therapy, Occupational Therapy and Physical Therapy Authorization Request Tips for Providers
Wheelchair and hearing aid repairs:
- CalOptima Health does not require prior authorization for wheelchair or hearing aid repairs less than $250.
- Covered benefit and frequency limitations will apply.
Prior Authorization Procedure Codes List
This is only a list of prior authorization procedure codes. It is not a complete description of benefits. For more information, contact CalOptima Health or read the Member Handbook.
Past Prior Authorization Procedure Codes List
Effective January–March 2025 (Physician-Administered Drug Prior Authorization Required List)
February 14–March 2025 (Medi-Cal)
Effective January–February 13, 2025 (Medi-Cal)
Effective October–December 2024 (Physician-Administered Drug Prior Authorization Required List)
Effective October–December 2024 (Medi-Cal)
Effective October–December 2024 (OneCare)
Effective July–September 2024 (Physician-Administered Drug Prior Authorization Required List)
Effective July–September 2024 (Medi-Cal)
Effective July–September 2024 (OneCare)
Effective April–June 2024 (Physician-Administered Drug Prior Authorization Required List)
Effective April–June 2024 (Medi-Cal)
Effective April–June 2024 (OneCare)
Effective January–March 2024 (Physician-Administered Drug Prior Authorization Required List)
Effective January–March 2024 (Medi-Cal)
Effective January–March 2024 (OneCare)
Effective October–December 2023 (Physician-Administered Drug Prior Authorization Required List)
Effective October–December 2023 (Medi-Cal)
Effective October–December 2023 (OneCare)
Effective July–September 2023 (Physician-Administered Drug Prior Authorization Required List)
Effective July–September 2023 (Medi-Cal)
Effective July–September 2023 (OneCare)
Effective April–June 2023 (Medi-Cal)
Effective April–June 2023 (OneCare)
Effective April–June 2023 (Physician-Administered Drug Prior Authorization Required List)
Since January 1, 2023, OneCare’s Medi-Cal Wrap Services are reviewed by CalOptima Health for all health networks.
These services include but are not limited to incontinence supplies, hearing aids and evaluations, Long-Term Care (LTC), and Community-Based Adult Services (CBAS). Please see the Medi-Cal Wrap Services Authorization List and instructions on how to submit your request to CalOptima Health via the Provider Portal.
For information on LTC and CBAS services, please see Long-Term Services and Supports.
For CalOptima Health Community Network
- CalOptima Health Direct (CHOD) members without an assigned PCP do not require authorization for initial consult visits.
- Prior authorization is not required for UCI Medical Center specialty follow-up visits for CalOptima Health Community Network (CHCN) members, except for extended visits (99215).
- All services provided by non-contracted providers require prior authorization, regardless of whether the codes are listed on the CalOptima Health Prior Authorization Required List.
- Codes not on the CalOptima Health Prior Authorization List are subject to Medi-Cal benefit and quantity limitations. Please check the Medi-Cal website for these determinations.
- Behavioral health codes for Medi-Cal and OneCare members are included on this list.
- All “By Report” codes require prior authorization.
- Prior authorization is NOT required for:
- Emergency services
- Urgent care visits
- Sensitive services (including family planning)
- Sexually transmitted disease services
- Abortion
- Minor consent services
- Human immunodeficiency virus (HIV) testing
- Basic prenatal care services
- Routine obstetrics services
- Pediatric preventive services
- Primary and preventive care services
CalOptima Health Community Network Prior Authorization
Primary Care
Prior authorization is NOT required for:
- Assigned PCP
- Affiliated group physician
Specialty Care (SCP)
All initial requests for specialty consults require a prior authorization from:
- Assigned PCP
- Contracted SCP
The initial prior authorization will include:
- One specialty consult
- As many routine follow-ups as necessary (excluding office code 99215, which requires a new prior authorization)
Urgent Referrals (PCP and SCP)
Urgent referrals are only to be submitted if the normal time frame for authorization will:
- Be detrimental to the patient's life or health
- Jeopardize patient's ability to regain maximum function
- Result in loss of life, limb or other major bodily function
All referrals not meeting urgent criteria will be downgraded to a routine referral request and follow routine turnaround times.