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. a 5 p. m. Lunes a viernes (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.