Prior Authorization Process
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Ancillary
PPO members are responsible for initially contacting Health Net. Health Net also requires participating hospitals and ancillary providers to request prior authorization.
Health Net members and providers may contact Health Net – Prior Authorization for prior authorization.
The following steps outline the process when a member or provider contacts Health Net – Prior Authorization.
- A Health Net representative answers the initial call and requests member information, physician name, member identification number, details regarding the procedure, and any other pertinent information, including other insurance.
- A tracking number is assigned and used for future calls to expedite locating the correct case.
- The Health Net representative will submit the Prior Authorization request to the Health Net Medical Management Department for review and processing.
- Health Net Medical Management will review the request with all the pertinent information and issue a determination.
- Notification of approvals and denials will be made to the requesting provider within 24 hours of the decision by either fax, phone or electronic notice.
- The Health Net Medical Management Department will issue a written notice of the determination to the member and provider.
- If the request for authorization is denied, the right to appeal is communicated to both the provider and the member.
If the participating hospital, ancillary provider or member does not obtain prior authorization before receiving services and the services are not for emergency care, a financial penalty may be imposed and the member's benefits are reduced, or the services may be denied in totality if deemed not medically necessary. The penalty varies by plan, but a typical example is that benefits are reduced by a percentage or dollar amount and an additional copayment may need to be satisfied.