The NEMS MSO Utilization Management (UM) team reviews treatment authorization requests (TARs) submitted by providers. Services that require prior authorization varies between plans. TARs, and the supporting clinical documentation, may be submitted by fax or through the NEMS MSO Provider Portal (EZ-NET).

Download the Treatment Authorization Request (TAR) Form

The UM team uses evidence-based clinical criteria and makes UM decisions timely. The turnaround time for decisions and notifications are as follows:

TAR Receipt Decision Decision if Pend Member Notification of Final Decision Provider Notification of Final Decision
Routine Day 0 Within 5 business days from Day 0 Up to 14 calendar days from Day 0 In writing within 2 business days from the decision, but not to exceed 14 calendar days from Day 0 Initially by telephone or fax and then in writing within 24 hours from the decision, but not to exceed 14 calendar days from Day 0
Urgent Day 0 72 hours from Day 0 72 hours from Day 0 In writing within 24 hours from the decision, but not to exceed 72 hours from Day 0 Initially by telephone or fax and then in writing within 24 hours from the decision, but not to exceed 72 hours from Day 0
Concurrent (inpatient) Day 0 72 hours from Day 0 72 hours from Day 0 In writing within 24 hours from the decision, but not to exceed 72 hours from Day 0 (excluding approvals) Initially by telephone or fax and then in writing within 24 hours from the decision, but not to exceed 72 hours from Day 0
Retrospective Day 0 30 calendar days from Day 0 N/A In writing within 30 calendar days from Day 0 In writing within 30 calendar days from Day 0

Authorization Required No Authorization Required

  • Acupuncture

  • Allergy Injections

  • Ambulatory Surgery Services

  • Audiological Services

  • Bone Density Studies

  • Chemical Dependency Services

  • Chemical Dependency Services

  • Chemotherapy

  • Chiropractic

  • Colonoscopy / Sigmoidoscopy (diagnostic)

  • Cardiac non-invasive test

  • Computerized Tomography (CT) Scans

  • Custodial Care

  • Durable Medical Equipment (DME)

  • Elective Sterilization

  • Electric Breast Pump (hospital grade)

  • Experimental / Investigational Treatment

  • Gamma Immune Therapy

  • Gender Reassignment

  • Genetic Testing

  • Hearing Aids

  • Home Health Care / Home Infusions Services

  • Hospice Care for general inpatient level of care

  • Hospital Admission

  • Laboratory Procedures costing over $300

  • Magnetic Resonance Imaging / Angiography (MRI/MRA)

  • Non-Emergency Medical Transportation

  • Nuclear Medicine Studies

  • Obstetric Procedures (include amniocentesis / more than 1 ultrasound)

  • Office Procedures costing over $300

  • Outpatient Hospital Procedures (include imaging and other ancillary services done in the out-patient hospital setting)

  • PET Scans

  • Renal Dialysis

  • Sleep Studies

  • Specialist to Specialist Referrals

  • Skilled Nursing and Intermediate Care

  • Surgeries

  • Therapy Services (include PT, OT, Speech)

  • Transplant

  • Sensitive Services – Medi-Cal members may self-refer to any providers for pregnancy testing, family planning services, HIV testing, abortion services, and treatments of sexually transmitted diseases

  • Abortion Services – Outpatient services do not require prior authorization, unless hospitalization is needed

  • EPSDT/CHDP services provided by PCP, FQHC, community clinic, DPH per EPSDT/CHDP periodicity schedules and guidelines

  • OB/GYN Services – A member may self-direct to in-network providers for obstetrical and gynecological services

  • Tuberculosis Care – Tuberculosis screening, testing, and treatment, do not require prior authorization, unless hospitalization is needed

  • Well Woman Care – Services provided according to ACOG guidelines with emphasis on preventive screening, including routine Pap smear, breast exam, and mammography, do not require prior approval

  • Hospice Care – Authorization is not required for routine home care, continuous home care, respite care, custodial care, or for hospice physician services

  • Preventive Care Screening – Screening colonoscopy/sigmoidoscopy, cervical cancer screening, breast cancer screening

  • Biomarker Testing (effective 7/1/2022) – Authorization is not required for members with advanced or metastatic stage 3 or 4 cancer for FDA-approved therapy

  • Non-Medical Transportation – Contact member’s health plan

  • COVID-19 Therapeutics – Authorization is not required for medically necessary COVID-19 therapeutics

Authorization for the below services are not processed by NEMS MSO

Please contact the entities responsible for the following services:

  • Mental Health (outpatient): For mild to moderate or outpatient behavioral health services, please contact your plan’s mental health benefit administrator.

    San Francisco Health Plan (SFHP) members: Call Beacon Health Options at 1-855-371-8117

    Anthem Blue Cross members: Call Anthem Blue Cross at 1-888-831-2246

  • Behavioral Health (inpatient): For inpatient mental health or specialty mental health, contact your county’s behavioral health department.

    San Francisco County: Call San Francisco Behavioral Services at 1-888-246-3333

    Santa Clara County: Call Santa Clara County Behavioral Health at 1-800-704-0900

  • Vision: Call Vision Service Plan (VSP) Vision Care at 1-800-438-4560

  • Dental: Call Denti-Cal at 1-800-322-6384

Authorization Required No Authorization Required

  • Allergy Injections

  • Ambulatory Surgery Services

  • Bone Density Studies

  • Chemical Dependency Services

  • Chemical Dependency Services

  • Chemotherapy

  • Chiropractic

  • Colonoscopy / Sigmoidoscopy (diagnostic)

  • CT Scans / MRI / PET Scans

  • Cardiac non-invasive test

  • Custodial Care

  • Durable Medical Equipment (DME)

  • Elective Sterilization

  • Electric Breast Pump (hospital grade)

  • Gamma Immune Therapy

  • Gender Reassignment

  • Genetic Testing

  • Home Health Care / Home Infusions Services

  • Hospital Admission

  • Laboratory Procedures costing over $300

  • Nuclear Medicine Studies

  • Obstetric Procedures (include amniocentesis / more than 1 ultrasound)

  • Office Procedures costing over $300

  • Outpatient Hospital Procedures (include imaging and other ancillary services done in the out-patient hospital setting)

  • Renal Dialysis

  • Sleep Studies

  • Specialist to Specialist Referrals

  • Skilled Nursing and Intermediate Care

  • Surgeries

  • Therapy Services (include PT, OT, Speech)

  • Transplant

  • OB/GYN Services – A member may self-direct to in-network providers for obstetrical and gynecological services

  • Tuberculosis Care – Tuberculosis screening, testing, and treatment, do not require prior authorization, unless hospitalization is needed

  • Well Woman Care – Services provided according to ACOG guidelines with emphasis on preventive screening, including routine Pap smear, breast exam, and mammography, do not require prior approval

  • Preventive Care Screening – Screening colonoscopy/sigmoidoscopy, cervical cancer screening, breast cancer screening

Authorization for the below services are not processed by NEMS MSO

Please contact the entities responsible for the following services:

  • Acupuncture: Call American Specialty Health Plans of California at 1-800-678-9133

  • Mental Health: Call Managed Health Network at 1-800-646-5610

  • Audiology and Hearing Aids: Call Hearing Care Solutions at 1-866-344-7756

  • Hospice: Call Health Net Member Services at 1-800-431-9007 to change to fee-for-service Medicare

Important Notice:

  1. NEMS MSO reserves the right to review and modify authorization requirement based on established criteria and/or community standards of practice
  2. Payment is contingent upon eligibility at the time of service
  3. Provider is responsible for verifying member eligibility prior to rendering services