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Prior Authorization

Please note, failure to obtain authorization may result in administrative claim denials. Health Net providers are contractually prohibited from holding any member financially liable for any service administratively denied by Health Net for the failure of the provider to obtain timely authorization.

Check to see if a pre-authorization is necessary by using our Medicare Pre-Auth Check tool. You can also refer to the following guides:

Expand the links below to find out more information.

All services are subject to benefit plan coverage, member eligibility and medical necessity, irrespective of whether prior authorization is required. When faxing a request, please attach pertinent medical records, treatment plans, and test results to support the medical appropriateness of the request. Health Net reserves the right to review utilization patterns retrospectively and to address adverse trends with providers.

Referrals to participating specialists – Providers are not required to obtain prior authorization from Health Net for referrals to Health Net participating specialists. For MA PPO plans, prior authorization may be required for out-of-network coverage. Unless noted differently, all services listed in the Prior Authorization & Appeals Guides (links above) require prior authorization from Health Net. Refer to Prior Authorization Contacts for submission information. Providers can refer to the member’s Health Net identification (ID) card to confirm product type.

This prior authorization list contains some services that require prior authorization only and is not intended to be a comprehensive list of covered services. The member’s plan contract or Evidence of Coverage (EOC) provides a complete list of covered services. Plan contracts and EOCs are available to members on the member portal at www.healthnet.com or in hard copy on request. Providers may obtain a copy of a member’s plan contract or EOC by requesting it from the Health Net Customer Contact Center.

Some services require prior authorization from Health Net in order for reimbursement to be issued to the provider.

For forms and details, see:

Medicare Prior Authorization & Appeals Guide (PDF)

Commercial Prior Authorization & Appeals Guide (PDF)

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

Health Net’s Medical Management department hours of operation are 8:00 AM to 5:00 PM Pacific time (excluding holidays). After normal business hours, Envolve nurse line staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.