Prior Authorization Process
- Participating Physician Groups (PPG)
PPO members are responsible for initially contacting the Health Net Medical Management Department . Health Net also requires participating hospitals and ancillary providers to call directly for prior authorization.
Health Net members and providers may contact the Health Net Medical Management Department for prior authorization.
The following steps outline the process when a member contacts the Health Net Medical Management Department:
- A Health Net intake coordinator 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
- When all information is received and the procedure is approved, a Health Net Medical Management Department staff member calls the provider and assigns an authorization number, which serves as an identification number for the service
- If the request for authorization is denied, Health Net notifies the member and hospital or ancillary provider by telephone followed by a written notice in accordance with PPO guidelines. At the time of the denial, 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.