Prior Authorization Process for Direct Network Providers
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
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 can fax requests for prior authorization to the Health Net – Prior Authorization using the appropriate form listed below:
The Health Net Medical Management Department accepts prior authorization requests for elective and urgent services by fax, phone or online.
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).
Contact the Health Net – Prior Authorization or visit the Health Net provider website to obtain the status of an authorization.
Allow 5 business days (Commercial) / 7 calendar days (Medicare) for routine organization determinations and 72 hours for expedited organization determinations.
Behavioral health authorization process
Health Net has licensed clinical staff available 24 hours a day, seven days a week to provide prior authorization for acute inpatient care. Patient care is pre-certified when a treating practitioner or facility submits initial clinical information and requests authorization prior to admission.
If authorization cannot be obtained before admission, Health Net requires facilities to submit authorization requests within 24 hours of admission to any higher level of care treatment service. These services include mental health and substance use disorder inpatient care, acute detox, residential treatment, partial hospitalization, and intensive outpatient programs.
Except in cases of extenuating circumstances, failure to request authorization within 24 hours of admission may result in denial of authorization.
Prior authorization procedures
- Facility providers must contact Health Net to request prior authorization. The preferred method for submitting prior authorization requests is online through the Availity Essentials secure provider portal (for Ambetter HMO/PPO, Employer Group HMO/POS, and Wellcare by Health Net members). If unable to submit online, refer Behavioral Health Contact information page for Prior Authorization contacts.
- Health Net Utilization Review Clinicians conduct prior authorization reviews according to the following guidelines:
- The Utilization Review Clinician assesses the patient’s clinical presentation according to medical necessity guidelines for the specific care setting, plan type, and intensity of service being proposed. This assessment includes the patient’s presenting problem, mental status, current diagnosis, previous psychiatric or substance abuse treatment, and relevant psychosocial factors.
- If medical necessity criteria for the requested level of care are met, the facility provider is given both verbal and written authorization. If the prior authorization occurs during non-regular business hours, the authorization is issued as “pending eligibility verification.” The facility provider is instructed to admit the patient to the proposed care setting and contact Health Net during regular business hours to verify eligibility.
- If medical necessity criteria are not met, the facility provider is notified verbally, and an alternative care plan or setting is discussed. If an agreement is reached, written confirmation of the alternative plan is provided. If no agreement can be reached, the Utilization Review Clinician explains the secondary review process and refers the case to a Health Net medical director for further evaluation.
Initial Authorization
- Facility providers initiate requests for authorization through the Availity Essentials secure provider portal, or if unable to submit online via fax or phone, for all higher levels of care.
- A Health Net Utilization Review Clinician reviews requests for medical necessity and applies medical necessity criteria.
- If the case does not appear to meet medical necessity criteria for the level of care requested, the Utilization Review Clinician refers the case to a Health Net medical director for review.
- If the medical director denies authorization, refer to the non-certification procedure.
- Once authorization is established, the Utilization Review Clinician notifies the requesting facility of the decision and sets a date for concurrent review.
- The Utilization Review Clinician generates an authorization verification letter to be mailed to the provider and patient.
Emergency services do not require prior authorization.