20-088 Prior Authorization Requirements
Date: 01/24/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Additions and changes, effective April 1, 2020
Medi-Cal fee-for-service providers
See below for prior authorization (PA) requirement changes for Health Net’s* Medi-Cal fee-for-service (FFS) providers. “New” indicates new requirement.
Requirement | Comments | Adult members ages 21 and over | Pediatric members under age 21 |
Continuous glucose monitoring | Listed under Durable Medical Equipment (DME) | New benefit | Existing benefit under CCS.1 |
H. pylori (Helicobacter pylori), antibody testing | Listed under Outpatient Procedures | New | |
Transplant | Listed under Outpatient Procedures | Removed HLA typing | |
Added Transplants must be performed through Health Net’s designated transplantation specialty network | |||
Aliqopa™, azedra®, Beouvu®, Besponsa®, Folotyn®, Kanuma®, Lutathera®, Polivy™ | Listed under Outpatient Pharmaceuticals | New | |
1CCS – California Children’s Services
Commercial providers
See the PA requirement changes on page 2 for Health Net’s commercial and Medicare HMO (MA HMO) fee-for-service providers. Commercial includes HMO, EPO, Health Care Service Plan (HSP), CommunityCare, CommunityCare participating physician groups (PPGs), Point of Service (POS) Tier 1, POS Tiers 2 and 3 (Elect, Select and Open Access), PPO, out-of-state PPO, and Flex Net products.
“New” indicates new requirement and “N/A” indicates not applicable.
Application of authorization requirement changes to EPO, PPO, OOS PPO, and Flex Net are based on group renewal date. Contact Health Net to confirm if specific services require PA for group plans.
Requirement | Comments | Lines of Business | |
Commercial | MA HMO | ||
Continuous glucose monitoring | Listed under Durable Medical Equipment (DME) | N/A | New |
Transplant | Listed under Outpatient Procedures | Removed HLA typing | |
Added Transplants must be performed through Health Net’s designated transplantation specialty network | |||
Aliqopa™, azedra®, Beouvu®, Besponsa®, Folotyn®, Kanuma®, Lutathera®, Polivy™ | Listed under Outpatient Pharmaceuticals (Submitted under Medical Plan) | New | N/A |
Remodulin® | Listed under Outpatient Pharmaceuticals | New | Existing |
Centene Corporation Employee PPO services
See below PA requirement changes for Centene Corporation Employee PPO medical benefits plans.
Requirement | Comments |
Transplant | · Removed HLA typing · Added Transplants must be performed through Health Net’s designated transplantation specialty network |
Aliqopa™, azedra®, Beouvu®, Besponsa®, Folotyn®, Kanuma®, Lutathera®, Polivy™, Remodulin® | Listed under Outpatient Pharmaceuticals (Submitted under Medical Plan) |
View PA requirements online
You can access prior authorization requirements and how to submit requests using the directions below.
If you are servicing a member enrolled in… | Access prior authorization requirements with these steps |
| 1 Go to provider.healthnet.com 2 Pre-log in, select Working with Health Net > Policies for Non-Contracting Providers > Additional Resources > Services Requiring Prior Authorization 3 Post-log in, select Working with Health Net > Contractual > Services Requiring Prior Authorization |
Individual MA HMO and Special Needs Plan (SNP) | 1 Go to ca.healthnetadvantage.com 2 Select I’m A Provider > Medicare 3 Enter the service code 4 If the code requires prior authorization, log in to provider.healthnetcalifornia.com to submit an authorization request
|
| 1 Go to ifp.healthnetcalifornia.com 2 Select For Providers 3 Enter the service code 4 If the code requires prior authorization, log in to provider.healthnetcalifornia.com to submit an authorization request |
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
EnhancedCare PPO (IFP) | 1-844-463-8188 | provider.healthnetcalifornia.com | provider_services@healthnet.com |
EnhancedCare PPO (SBG) | 1-844-463-8188 | provider.healthnet.com | |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider.healthnet.com | |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | provider.healthnetcalifornia.com | |
Medicare (individual) | 1-800-929-9224 | provider.healthnetcalifornia.com | |
Medicare (employer group) | 1-800-929-9224 | provider.healthnet.com | |
Medi-Cal | 1-800-675-6110 | provider.healthnet.com | N/A |