Prior Authorization Process for Direct Network Providers
- Participating Physician Groups (PPG)
(does not apply to HSP)
Selected specialty and outpatient services that cannot be provided in a primary care physician's (PCP's) or specialist's office require prior authorization as outlined in the Commercial Prior Authorization Requirements or the Medicare Prior Authorization Requirements.
PCPs and specialists must fax requests for prior authorization to the Health Net Medical Management Department using the appropriate form listed below:
- Inpatient California Health Net Commercial Prior Authorization (PDF)
- Outpatient California Health Net Commercial Prior Authorization (PDF)
- Inpatient California Health Net Medicare Authorization (PDF)
- Outpatient California Health Net Medicare Authorization (PDF)
The Health Net Medical Management Department accepts prior authorization requests for elective and urgent services by fax only.
To initiate the prior authorization process, PCPs and specialists must:
- Verify member eligibility and benefit coverage by accessing the Health Net provider portal or by contacting the Health Net Provider Services Center.
- Complete the prior authorization form, including CPT codes and sufficient clinical information to support the medical necessity of the request. Incomplete forms or forms with insufficient information at the time of submission delay processing (some surgical requests, such as requests for reconstructive surgery or repair require submission of non-returnable color photos, models or X-rays).
Allow 14 calendar days for routine organization determinations and 72 hours for expedited organization determinations.
Emergency services do not require prior authorization.