Prior Authorization Requirements


Effective May 24, 2024

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

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

These are subject to prior authorization 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) provides a complete list of covered services. EOCs may be available online 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 or online. 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.

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.

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

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.

1Direct Network refers to Health Net’s directly contracting network for HMO, Ambetter HMO 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.

Services outside of California – PPO plans that include travel benefits and out-of-state PPO plans: Inpatient services and medical oncology require prior authorization. Verify member eligibility through the Health Net Provider Services Center prior to providing care. Services provided within California follow the requirements and directions below.