- If a code is not listed on the Prior Authorization Required List, then it requires prior authorization.
- Non-contracted providers billing Medi-Cal, HealthWorx or Healthy Kids must also obtain a Referral Authorization Form from the member’s PCP before seeing the member or providing any non-emergency services.
- All non-contracted providers must obtain prior authorization for hemodialysis services.
- Non-emergency transport requires prior authorization (except where noted on the PAR list).
- Codes highlighted on the PAR list do not require prior authorization when provided in an inpatient setting.
- DME: see the PAR list.
- Hearing Aids require prior authorization: see the PAR list.
- Incontinence providers should refer to the HPSM Incontinence Supply Formulary.
- The combination of outpatient PT/OT/ST requires prior authorization starting on the 21st annual visit per member. (This allowance was instituted on 3/1/2017 retro back to date of service 9/1/2016.)
- Outpatient PT/OT/ST authorizations are required for all visits for HPSM members under 21.
- IEPs are required to authorize outpatient ST for HPSM members 3-18 in school or daycare who receive therapy in that setting.
- Home Health (g codes) requires prior authorization for all services.
- All unlisted codes require prior authorization.
- All services requiring written MD orders must be submitted with prior authorization requests.
Prior Authorization List
IMPORTANT NOTE: Prior authorization is based on medical necessity and is not a guarantee of coverage or eligibility. If a service is not included on this list, the service does not require prior authorization. However, this does not mean it is a covered benefit.
Only valid codes will be reviewed. Please refer to CMS/MC guidelines to verify validity. Codes are updated regularly and posted below.
It is expected that all services requiring prior authorization must be authorized before providing the service, with the exception of services that are necessary on an emergent or truly urgent basis. Before submitting a request, search HPSM's Prior Authorization List by CPT code or service name to see if you need to get prior authorization:
Download the PAR List: Prior Authorization Required List
To use spreadsheet functions, download the Excel file: Prior Authorization Required List
List last Updated 4/01/2019
Prior Authorization List Changes
HPSM periodically updates our list of codes requiring prior authorization to reflect current clinical guidelines. You can review these changes or archived lists on the PAR List Changes page.