Changes to Prior Authorization Search Tool in Provider Portal
| Date: | September 11, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Providers, Facilities and Hospitals |
| Type: | Informational |
| Subject: | Changes to Prior Authorization Search Tool in Provider Portal |
| Business: | Medi-Cal Managed Care |
Health Plan’s current claims processing system upgrade to QNXT 2.0 scheduled for September 12, 2025, includes an enhancement to the provider portal, Doctors Referral Express (DRE).
- The Search Codes feature in DRE will be replaced with the Prior Authorization Procedure Codes List, which provides a comprehensive, searchable list of procedure codes (CPT/HCPCS) and associated prior authorization requirements, valid for participating, (network) providers only. The list will be updated periodically to align with code changes and other updates. In addition:
- All elective services at a tertiary level of care center require prior authorization
- Scheduled inpatient admissions require prior authorization
Non-participating, tertiary, and participating out-of-area providers, please note:
All services require prior authorization, except for the following services:
- Emergency Services
- Family Planning
- Sexually Transmitted Diseases
- HIV testing and counselling
- Minor Consent Services for Members < 18 years old
- Immunizations provided by local health departments
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
