- Participating Physician Groups (PPG)
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.
Obtaining prior authorization is the responsibility of directly contracting fee-for-service (FFS) providers and attending physicians. To obtain prior authorization from Health Net, fax a completed Inpatient California Medi-Cal Prior Authorization Form - (Medi-Cal PDF) (CalViva Health PDF) or the Outpatient California Health Net Prior Authorization Form - (Medi-Cal PDF) (CalViva Health PDF) to the Medical Management Department. FFS providers must refer to the Prior Authorization Requirements list for services that require prior authorization.
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. PPGs may not impose prior authorization requirements that conflict with the member's right to self-refer for certain services.
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.