Attachment B: Prior-Authorization Exemptions List

Services that do not require Treatment Authorizations prior to the rendering of care include:

All Providers:

  1. 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.

  2. Immunizations
    • Members may self-refer to Department of Public Health immunization clinics under "urgent need" conditions.

  3. 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:

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. Tuberculosis Care
    • Tuberculosis screening, testing, and treatment, does not require prior authorization, unless hospitalization is needed.

  6. 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.