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Requesting Prior Authorization or Coordinating a PCP Referral

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kings
  • Los Angeles
  • Madera
  • Sacramento
  • San Diego
  • San Joaquin
  • Stanislaus
  • Tulare

To request prior authorization or coordinate a primary care physician (PCP) referral for services other than advanced imaging services and cardiac imaging:

  • The PCP completes the Inpatient California Medi-Cal Prior Authorization (PDF) form or the Outpatient California Medi-Cal Authorization (PDF) form and sends it to the specialist
    • This ensures that the member is seeking services from in-network providers
  • The PCP and specialist retain a copy of the Ip or OP prior authorization form in the member's chart
  • Fax a copy of the prior authorization form to the Medical Management Department
    • This ensures that Health Net identifies case management needs and assists the member with coordination of care, when appropriate
    • This also enables Health Net to assist in the detection of and referral to appropriate agencies for carve-out services, such as California Children's Services (CCS)
  • Specialists submitting paper claims to Health Net must include the prior authorization form with the claim
    • This supports the PCP-to-specialist referral and helps prevent delays in payment
  • Specialists submitting electronic claims must indicate the name of the referring provider in box 23 of the CMS-1500 claim form

The PCP or specialist must give the Medical Management Department as much advance notice as possible when requesting prior authorization. For elective inpatient or outpatient services, fax requests for prior authorization at least five days before the anticipated date of service. It is recommended not to schedule services prior to receiving the review decision. The Medical Management Department needs time to notify the provider of the review decision prior to the services being rendered.

Required Information

Submit the following information when requesting prior authorization:

  • Member's name
  • Member's identification number
  • Member's date of birth
  • Diagnosis
  • Requesting physician's name, address, telephone and fax numbers, and contact person
  • Place where services are provided
  • Physician's name (physician receiving referral), ancillary provider name and facility name
  • Procedures
  • Date of service

The Medical Management Department reviews the information and calls back with the review decision. If the service is authorized, an authorization number is given.

Submission of Prior Authorization Requests

Fax the prior authorization form to the Medical Management Department. Use the fax number on the form to submit requests 24 hours a day, seven days a week. 

 

Last Updated: 11/12/2020