Prior Authorization Requirements


Effective July 1, 2023

The services, procedures, equipment and outpatient pharmaceuticals below apply to:

  • Direct Network1 HMO (including Ambetter HMO) and Point of Service (POS) Tier 1
  • Health Care Service Plan (HSP)
  • POS Tiers 2 and 3 (Elect, Select and Open Access)             
  • Ambetter (Amb.) HMO participating physician groups (PPGs)
  • EPO, PPO, out-of-state PPO and Flex Net

These are subject to prior authorization (PA) requirements (unless noted as "notification" required only) if an “X” is included under the applicable line of business. If “X” is not present, PA may not be required or the service may not be a covered benefit. PA is guaranteed only as of the time of access to this prior authorization requirements page. Providers are responsible for verifying member eligibility through the Health Net Provider Services Center prior to providing care. Even if a service or supply is authorized, eligibility rules and benefit limitations will still apply.

For Individual plans, to confirm whether a specific code requires authorization go to: IFP Ambetter HMO or IFP Ambetter PPO and follow the prompts.

This PA list is not intended to be a list of covered services. The member’s Evidence of Coverage (EOC) or Certificate of Insurance (COI) provides a complete list of covered services. EOCs and COIs may be available online at to members on the Health Net website or by requesting them from the Health Net Provider Services Center.

Submit a prior authorization request to Health Net unless stated differently in requirements listed below. Refer to the member’s Health Net identification (ID) card to confirm product type. Requests should be submitted to Health Net via fax. The Health Net Request for Prior Authorization form must be completed in its entirety and include sufficient clinical information or notes to support medical necessity for services that are requested.

Services provided pursuant to a CARE agreement or CARE plan approved by a court do not require prior authorization.

When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. All services, procedures, equipment and outpatient pharmaceuticals are subject to benefit plan coverage limitations, members must be eligible, and medical necessity must exist for any plan benefit to be a covered service irrespective of whether or not PA is required.

Select lines of business are abbreviated as follows: Ambetter HMO PPGs is Amb. HMO PPGs, POS Tiers 1, 2 and 3 are POS T1, POS T2, POS T3; out­ of-state PPO is OOS PPO. Ambetter HMO utilizes the CommunityCare network.

Application of authorization requirement changes to EPO, PPO, OOS PPO and Flex Net are based on group renewal date. Contact Health Net to confirm whether specific services require PA for Group plans. 

1Direct Network refers to Health Net’s directly contracting network for HMO, Ambetter HMO, HSP and POS Tier 1 products.

If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.