Attachment B: Prior-Authorization Exemptions List
Services that do not require Treatment Authorizations prior to the rendering of care include:
- Sensitive Services
- Medi-Cal members may self-refer to any out-of-network providers for pregnancy testing, family planning services, HIV testing, and treatments of sexually transmitted diseases. For other lines of business, members may self-referred to NEMS panel providers for sensitive services.
- Abortion services is excluded in this category, please refer to the Abortion Services section for detail.
- Members may self-refer to Department of Public Health immunization clinics under "urgent need" conditions.
- Emergency Services
- Authorization is not required for emergency situations as defined by the examining physician, assessment and treatment must proceed until the patient is stabilized.
- Routine and non-urgent cares received in an emergency room setting require approval by the PCP.
- Out-of-Area emergency services will be covered with submission of medical documentation to proof the emergent medical condition.
- Routine and follow up care related to the emergency services should be directed back to the patient’s PCP office.
Panel Providers / Contracted Specialists Only:
- Abortion Services
- Members may self-refer for outpatient abortion services if under 20 gestational weeks of pregnancy, but must see a provider that is contracted with NEMS Medical Group.
- Prior authorization stating medical justification is required if abortion service over 20 gestational weeks of pregnancy.
- CHDP/EPSDT Preventive Services
- EPSDT and CHDP services provided by PCP, FQHC, community Clinic, DPH per EPSDT/CHDP periodicity schedules and guidelines, no prior-authorization is required.
- OB/GYN Services
- Members may self direct to any NEMS Medical Group’s affiliated obstetrician/gynecologist for gynecological and obstetrical services.
- Prior-authorization is required for hospital admission and testing outside of standards.
- Standing Referrals to Specialty Care
- A member with a life threatening, degenerative and disabling condition is eligible for a standing referral that allows the specialist to act as the care coordinator in lieu of the PCP.
- People with HIV/AIDS are eligible for a referral to an AIDS specialist who acts as the coordinator of care.
- The member is directed back to the PCP for unrelated problems.
- Tuberculosis Care
- Tuberculosis screening, testing, and treatment, does not require prior authorization, unless hospitalization is needed.
- Well Woman Care
- Services provided according to ACOG guidelines by a NEMS Medical Group’s affiliated providers with emphasis on preventive screening, including routine Pap smear, breast exam, and mammography, does not require prior approval.