21-749 Prior Authorization! Find Out What's New or Changing
Date: 10/27/21
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.
Drugs that require prior authorization now and other changes that start January 1, 2022
Health Net is implementing changes to the fee-for-service prior authorization (PA) requirements.
Medications that require PA immediately
- AduhelmTM, approved by the U.S. Food and Drug Administration (FDA) onJune 7, 2021.
- New injectable medication HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS) on July 1, 2021:
o Amondys 45TM | o Danyelza® | o MargenzaTM | o Pepaxto® |
- New injectable medication HCPCS codes issued by CMS on October 1, 2021:
o Cosela TM | o Jemperli® | o Rybrevant TM | o Zynlonta® |
Go online for current PA requirements
Use these directions to access current PA requirements and to submit a request:
If you are servicing a member | Then follow these steps… |
| 1 Go to the Provider Portal. 2 Pre-log in, select Working with Health Net > Additional Resources > Services Requiring Prior Authorization. 3 Post-log in, select Working with Health Net > Contractual > Services Requiring Prior Authorization. |
| 1 Go to the IFP Portal, select For Providers then select the product type. 2 Answer the questions at the bottom of the page, enter the code and press Check. 3 If the code requires a PA, click on Login Here to submit a request. |
Medi-Cal fee-for-service
The below PA requirement changes are for Health Net’s Medi-Cal fee-for-service providers. “New” indicates new requirement, “Existing” indicates current requirement and “N/A” indicates not applicable.
Requirement | Comments | Adult members ages 21 and over | Pediatric members under age 21 |
|---|---|---|---|
Additions, effective January 1, 2022 | |||
Community Supports
| More information will be available | New | New |
Enhanced care management (ECM) |
| New | New |
Major organ transplant |
| New | New |
Outpatient Pharmaceuticals (submitted under Medical Plan) | Abecma®, EmpaveliTM, Fensolvi®, Nexviazyme®, Sotradecol® | New | New |
Deletions, effective January 1, 2022 | |||
Testing and in-office procedures performed by pediatric sub-specialists | Procedures, Services or Equipment specifically named on the authorization list continue to require authorization. | N/A | Existing |
Wheelchair repairs and accessories for adult members with billed charges under $1,500 | Listed under Durable medical equipment (DME), Outpatient Procedures, Services or Equipment. | Existing | N/A |
Commercial and Ambetter
Select lines of business have been abbreviated as follows: Ambetter HMO PPGs is Amb. HMO PPGs; POS Tiers 1, 2 and 3 are POS T1, POS T2 and POS T3; out-of-state PPO is OOS PPO. Application of authorization requirement changes to EPO, PPO, OOS PPO, and Flex Net are based on group renewal date. Contact Health Net to confirm whether specific services require PA for group plans. “New” indicates new requirement, “Existing” indicates current requirement and “N/A” indicates not applicable.
Requirement | Comments | Line of business | |||
|---|---|---|---|---|---|
HMO, HSP, POS T1 | Amb. HMO PPGs | POS T2, POS T3 | EPO, PPO, OOS PPO, Flex Net | ||
Additions, effective January 1, 2022 | |||||
Ear, nose, throat (ENT) services | Inpatient and outpatient ENT services will be authorized by TurningPoint Healthcare Solutions, LLC. Refer to 21-743, Prior Authorization Changes for Cardiovascular and ENT Procedures for more information. | N/A | N/A | N/A | New |
Cardiac procedures | Inpatient and outpatient cardiac procedures will be authorized by TurningPoint Healthcare Solutions, LLC. Refer to 21-743, Prior Authorization Changes for Cardiovascular and ENT Procedures for more information. | N/A | N/A | N/A | New |
Continuous glucose monitoring |
| N/A | N/A | N/A | New |
Outpatient Pharmaceuticals (submitted under Medical Plan) | Abecma®, EmpaveliTM, Fensolvi®, Nexviazyme®, Sotradecol® | New | New | New | New |
| Deletions, effective January 1, 2022 | |||||
Wheelchair accessories | Listed under Durable medical equipment (DME), Outpatient Procedures, Services or Equipment | Existing | Existing | Existing | Existing |
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 |
| |
EnhancedCare PPO (SBG) | 1-844-463-8188 |
| |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 |
| |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 |
| |
Medi-Cal | 1-800-675-6110 |
| N/A |