Prior Authorizations
For some types of care, your PCP or specialist will need to ask PHC California for permission before you get the care. This is called asking for pre-approval or prior authorization. It means PHC California must make sure the care is medically needed.
The following services always need pre-approval (prior authorization), even if you get them from a provider in the PHC California network:
- Hospitalization, if not an emergency
- Services out of the PHC California service area, if not an emergency or urgent care
- Outpatient surgery
- Long-term care or skilled nursing services at a nursing facility (including adult Subacute Care Facilities contracted with the Department of Health Care Services Subacute Care Unit) or intermediate care facilities (including Intermediate Care Facility for the Developmentally Disabled (ICF/DD), ICF/DD-Habilitative (ICF/DD-H), ICF/DD-Nursing (ICF/DD-N))
- Specialized treatments, imaging, testing, and procedures
- Medical transportation services when it is not an emergency
Additional Information on Prior Authorizations
For a more full description of these covered services that may require prior authorization, please see Chapter 4 of the Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective February 1, 2026).
- Acute (short-term treatment) home health therapies and services
- Allergy testing and injections
- Chemotherapy & radiation therapy
- Community Supports
- Dialysis/hemodialysis services
- Durable medical equipment (DME)
- Enhanced Care Management (ECM) services
- Habilitative services and devices
- Hearing aids
- Home health care
- Hospice care (inpatient only)
- Inpatient medical and surgical care
- Long-term home health therapies and services
- Long-term services and supports
- Occupational therapy
- Organ and bone marrow transplant
- Orthotics/prostheses
- Outpatient hospital services
- Outpatient surgery
- Physical therapy
- Rehabilitation services and devices
- Skilled nursing services, including subacute services
- Speech therapy
- Surgical services
- Transgender services
For a more full description of these covered services that do NOT require prior authorization, please see Chapter 4 of the Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective February 1, 2026)
- Acupuncture
- Ambulance services for an emergency
- Anesthesiologist services
- Asthma prevention
- Audiology
- Basic care management services
- Biomarker testing
- Cardiac rehabilitation
- Chiropractic services
- Cognitive health assessments
- Community Health Worker (CHW) services
- Complex Care Management (CCM) services
- Dental services – limited (performed by medical professional/primary care provider (PCP) in a medical office)
- Doula services
- Dyadic services
- Emergency room visits
- Enteral and parenteral nutrition
- Family planning services (you can go to an out-of-network provider)
- Gender-affirming care
- Health and Wellness benefit – gym membership or over-the-counter pharmacy merchandise
- Intermediate care facility services for developmentally disabled services
- Lab and radiology
- Maternity and newborn care
- Mental health treatment
- Ostomy and urological supplies
- Outpatient mental health services
- Palliative care
- PCP visits
- Podiatry services
- Pulmonary rehabilitation
- Specialist visits
- Telemedicine/Telehealth
- Transitional care services
- Urgent care
- Vision services
- Women’s health services
- PHC California gives standard prior authorization decisions in 7 calendar days. Standard decisions are also called non urgent.
- PHC California gives expedited prior authorization decisions in 72 hours. Expedited decisions are also called urgent.
For more information about prior authorizations and coverage decisions, please see the section titled, “Pre-approval (prior authorization)” in Chapter 3 of the Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective February 1, 2026).
PHC California creates a report of our prior authorization data for the prior year. This report helps members and providers see how the plan manages their prior authorizations. The report covers prior authorizations for medical services. It does not cover prior authorizations for prescription drugs.
For additional information or if there are any questions on prior authorizations, please contact the Utilization and Case Management Department at (800) 474-1434, Monday through Friday, 8:30 a.m. to 5:30 p.m. (TTY 711).
DHCS MMDDYY PHC FR Form 1.0