25-250 Refer Members to In-Network Providers to Minimize Out-of-Pocket Costs
Date: 03/19/25
Out-of-network referrals are only reimbursed in specific cases, such as emergencies, as required by law, or when prior authorized
When referring members to specialists or other providers for services beyond your scope, it’s crucial to consider the financial implications for the member. Referrals to out-of-network providers are typically not reimbursed except in specific situations, such as emergencies, as required by law, or when prior authorization has been granted.
To help ensure members avoid unnecessary expenses, always prioritize referring them to in-network providers whenever possible. Choosing in-network providers not only helps members avoid potential out-of-pocket costs but also ensures they receive care aligned with their plan’s coverage.
Exceptions for out-of-network referrals
Out-of-network referrals are permitted only under the following conditions:
- Emergency Situations: When immediate care is necessary.
- Legal Requirements: When federal or state law mandates out-of-network care.
- Prior Authorization: When approved in advance by Health Net or the delegated PPG.
If an exception applies, you must contact Health Net Provider Services or the delegated PPG to verify the necessity of the referral and obtain prior authorization.
How to locate a participating provider
To locate a participating provider, use the Find a Provider tool at Provider Search to determine if an out-of-network referral is necessary and request prior authorization.
Additional information
For additional information about referrals, please refer to the provider operations manual, available in the
Provider Library. Once in the library, select the applicable line of business, then Provider Manual > Referrals.
Provider Services
Line of business | Phone number | |
|---|---|---|
Ambetter from Health Net IFP Ambetter PPO | ||
Ambetter HMO | ||
Health Net Employer Group HMO, POS, & PPO | ||
Medicare (Individual & Employer Group) (Wellcare By Health Net) | ||
Medicare Supplement | ||
Medi-Cal (including CS and ECM providers) | N/A | |
Behavioral Health providers | N/A |
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.