Prior Authorization
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Prior authorization ensures medical necessity of services and level of care, and the use of participating providers, as well as to prevent unanticipated denials of coverage.
Refer to the PA Requirements List to determine which service require prior authorization and for information on where to submit PA requests based on the type of service, drug, device or procedure.
Health Net has delegated the prior authorization process to some participating physician groups (PPGs). Prior authorizations for members assigned to a capitated PPG are subject to any additional rules imposed by the PPG. PPGs may not impose prior authorization requirements that conflict with the member's right to self-refer for services. Refer to the PPG for authorization requirements.
When to submit prior authorization requests to local county CCS agency
Specialists are required to send copies of consultation and treatment plans to the member's primary care physician (PCP) and all participating providers are required to refer any services related to a California Children's Services (CCS)-eligible condition to the local county CCS agency for authorization. CCS-eligible services must be provided by a CCS-paneled provider at CCS-approved facilities.