Prior Authorizations
For some types of care, PHC California providers will need to ask for pre-approval or prior authorization before providing care. This allows PHC California to make sure the care is medically necessary.
The following services always need pre-approval (prior authorization), even if they are given 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
Prior Authorization requests must be made using the Prior Authorization Request Form. For additional information on prior authorizations or general plan information please consult the current PHC California Provider Manual (effective August 1, 2025).
Additional Information on Prior Authorizations
For a more complete description of these covered services that may require prior authorization, please see Section 4 of the PHC California Provider Manual (effective August 1, 2025).
- 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 complete description of these covered services that may not require prior authorization, please see Section 4 of the PHC California Provider Manual (effective August 1, 2025).
- 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
- Determinations regarding requests for elective services/procedures are made within seven (7) calendar days of request and receipt of medical record information required to evaluate medical necessity and appropriateness
- Determinations regarding urgent service/procedures are made within seventy- two (72) hours of receipt of medical record information required to evaluate medical necessity and appropriateness.
For transparency with our enrollees and providers, as well as alignment with the state and federal guidelines, PHC California publishes an annual report of our prior authorization metrics for the prior year. This report covers the prior authorization data for medical services (excluding prescription drugs).
