How to Fill Out and Submit the CalViva Prior Authorization Form

The CalViva prior authorization form is the Outpatient California Medi-Cal Authorization Form that providers in Fresno, Kings, and Madera counties use to get approval before delivering certain services to CalViva Medi-Cal members. You download the PDF from Health Net, complete the required member, provider, diagnosis, and procedure fields, attach supporting clinical records, and fax it to Health Net’s prior authorization department at 800-743-1655. Routine decisions come back within seven calendar days.¹

Where to Download the Form

The form is a PDF hosted on Health Net’s website.² The Health Net Provider Library’s prior authorization page links to the same document.³ CalViva contracts with Health Net Community Solutions to run utilization review, which is why the form and submission channels sit on Health Net’s systems.⁴

One boundary before you start: outpatient prescription drugs do not go on this form. Pharmacy benefits for Medi-Cal members are carved out to the state’s Medi-Cal Rx program and use their own forms and fax line.

How to Fill Out the Form

Required fields are marked with an asterisk. A blank or wrong entry in any of them is the quickest way to stall a review, so check each one against the member’s CalViva ID card and your own records before you send it.

Member ID, taken from the CalViva Health card.
Requesting NPI and, if different, Servicing NPI (ten digits each).
Primary diagnosis code in ICD-10.
Primary procedure code in CPT or HCPCS, with additional codes listed if the request covers more than one service.
Outpatient service type, selected from categories such as outpatient surgery, imaging, DME rental or purchase, and biopharmacy.
Requesting provider contact information, including office phone and fax, so clinical reviewers can reach you for clarification.²

Physician Signature

Urgent requests must be signed by the requesting physician to receive priority processing; the form states this at the top. A signature is still a good idea on routine requests, but without one the urgency flag will not be honored.²

Clinical Documentation to Attach

The form says in bold that copies of all supporting clinical information are required.² Attach what demonstrates medical necessity: progress notes, lab results, imaging reports, or a letter of medical necessity from the treating physician. A form with codes but no clinical backup is the most common reason reviews stall.

How to Submit It

Fax is the primary channel. Send the completed form and attachments to Health Net’s prior authorization department at 800-743-1655. You can also call the dedicated CalViva prior authorization line at 888-893-1569 to submit by phone or check status, or submit online through the Health Net provider portal at provider.healthnetcalifornia.com.⁵

For physical mail, send to the Health Net Prior Authorization Department, 21281 Burbank Blvd., Woodland Hills, CA 91367.⁵ Fax is almost always faster; mail only makes sense for non-urgent requests with bulky records.

Pharmacy Requests Go Elsewhere

Prescription drug prior authorizations for Medi-Cal members do not go through CalViva. Since the statewide Medi-Cal Rx carve-out, pharmacy benefits are administered by the Department of Health Care Services. Providers fax pharmacy PA requests to 1-800-869-4325 using the preferred DHCS 6560 form or an approved alternative (Form 50-1, Form 50-2, or California Form 61-211). You can also submit, check, cancel, or supplement a pharmacy PA through the Medi-Cal Rx Secured Provider Portal after registering.⁶ Paper requests go to Medi-Cal Rx Customer Service Center, ATTN: Provider PA Requests, P.O. Box 730, Rancho Cordova, CA 95741-0730.⁷

When You Actually Need to Submit the Form

Not every service requires prior authorization. Emergency services never do, and most in-network specialist visits and routine diagnostic services from participating providers are also exempt.⁸ The categories that do require approval include:

Inpatient admissions: elective medical and surgical hospitalizations, skilled nursing facility admissions, and long-term care nursing facility stays.
Elective outpatient surgery, including ankle, hip, knee, and shoulder joint procedures and bariatric and orthognathic surgery.
Advanced imaging: CT, CTA, MRI, MRA, PET, and cardiac imaging such as CCTA and MPI. Routine X-rays from in-network providers do not require authorization.
Durable medical equipment with a total Medi-Cal purchase price over $1,500, plus all DME for pediatric members.
Behavioral health: ABA for autism, out-of-network behavioral health access, and neuropsychological testing.
Private duty nursing covered under EPSDT.
Any referral to an out-of-network provider or facility.
Cochlear implants, genetic testing, outpatient infusion therapy, palliative care, prosthetics, and custom orthotics.

The full list is published on CalViva’s website and updated periodically; check the current version before you submit.⁹

How Long Decisions Take

The timeline clock starts when CalViva receives all the information it needs to decide.

Routine requests: seven calendar days. The plan can extend by up to 14 more calendar days if it needs additional information.¹
Urgent or expedited requests: 72 hours from receipt, available when a delay could seriously harm the member’s health or recovery.¹⁰
Urgent-concurrent requests: 24 hours, when the member is already receiving an authorized course of treatment and the request comes in at least 24 hours before the current authorization expires.¹⁰

Submit routine requests at least five business days before a scheduled procedure so the plan has runway to decide without bumping up against the appointment.⁹

If the Request Is Denied

The member, or a provider acting on the member’s behalf with written consent, can appeal within 60 calendar days of the denial notice. Appeals filed after that window are not considered. Standard appeals are resolved in 30 calendar days; expedited appeals, when a delay could seriously harm the member, are resolved within 72 hours.¹¹ Include any new clinical documentation that supports medical necessity. If the internal appeal is denied, the member can request an Independent Medical Review through the California Department of Managed Health Care within six months.¹²

1
CalViva Health. Member Resources
2
Health Net. CalViva Prior Authorization Form
3
Health Net. Request for Prior Authorization Form
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CalViva Health. Health Net of California CalViva Health UMCM Program Description
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Health Net. Health Net – Prior Authorization
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Medi-Cal Rx. Five Ways to Submit a Prior Authorization Request
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Medi-Cal Rx. Prior Authorization Submission Reminders
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CalViva Health. Prior Authorization Requests
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CalViva Health. CalViva Prior Authorization List 2025-08-01
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Health Net. Authorization and Referral Timelines – Medi-Cal
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Health Net. Member Appeals Overview – Medi-Cal
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Disability Rights California. Medi-Cal Managed Care: An Independent Medical Review (IMR) Can Change a Plan’s No to Yes