Prior Authorization Process
Provider Type
- Physicians and Practitioners
- 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.
Behavioral health authorization process
Health Net has licensed clinical staff available 24 hours a day, seven days a week to provide prior authorization for acute inpatient care. Patient care is pre-certified when a treating practitioner or facility submits initial clinical information and requests authorization prior to admission.
If authorization cannot be obtained before admission, Health Net requires facilities to submit authorization requests within 24 hours of admission to any higher level of care treatment service. These services include mental health and substance use disorder inpatient care, acute detox, residential treatment, partial hospitalization, and intensive outpatient programs.
Except in cases of extenuating circumstances, failure to request authorization within 24 hours of admission may result in denial of authorization.
Prior authorization procedures
- Facility providers must contact Health Net to request prior authorization. The preferred method for submitting prior authorization requests is online through the Availity Essentials secure provider portal (for Ambetter HMO/PPO, Employer Group HMO/POS, and Wellcare by Health Net members). If unable to submit online, refer Behavioral Health Contact information page for Prior Authorization contacts.
- Health Net Utilization Review Clinicians conduct prior authorization reviews according to the following guidelines:
- The Utilization Review Clinician assesses the patient’s clinical presentation according to medical necessity guidelines for the specific care setting, plan type, and intensity of service being proposed. This assessment includes the patient’s presenting problem, mental status, current diagnosis, previous psychiatric or substance abuse treatment, and relevant psychosocial factors.
- If medical necessity criteria for the requested level of care are met, the facility provider is given both verbal and written authorization. If the prior authorization occurs during non-regular business hours, the authorization is issued as “pending eligibility verification.” The facility provider is instructed to admit the patient to the proposed care setting and contact Health Net during regular business hours to verify eligibility.
- If medical necessity criteria are not met, the facility provider is notified verbally, and an alternative care plan or setting is discussed. If an agreement is reached, written confirmation of the alternative plan is provided. If no agreement can be reached, the Utilization Review Clinician explains the secondary review process and refers the case to a Health Net medical director for further evaluation.
Initial Authorization
- Facility providers initiate requests for authorization through the Availity Essentials secure provider portal, or if unable to submit online via fax or phone, for all higher levels of care.
- A Health Net Utilization Review Clinician reviews requests for medical necessity and applies medical necessity criteria.
- If the case does not appear to meet medical necessity criteria for the level of care requested, the Utilization Review Clinician refers the case to a Health Net medical director for review.
- If the medical director denies authorization, refer to the non-certification procedure.
- Once authorization is established, the Utilization Review Clinician notifies the requesting facility of the decision and sets a date for concurrent review.
- The Utilization Review Clinician generates an authorization verification letter to be mailed to the provider and patient.