Prior Authorization Rules for Medical Benefits |

Prior Authorization Rules for Medical Benefits


What is Prior Authorization?

A Prior Authorization is a decision made by the plan regarding certain medical services that require pre-approve, prior to furnishing, arranging for, or providing for the health care service. You, your representative, or your network Primary Care Provider (PCP), or the provider that furnishes or intends to furnish the services to you, may request a Prior Authorization by filing a request for Prior Authorization. The process is also referred to as a referral request. A referral means that your network PCP must give you approval before you can see the other provider. If you do not get a referral, Health Net may not cover the service.

Referrals from your network PCP are not needed for:

  • Emergency care,
  • Urgently needed care,
  • Kidney dialysis services that the enrollee gets at a Medicare-certified dialysis facility when the enrollee is outside the plan's service area, or
  • To see a women's health specialist.
  • Additionally, if you are eligible to receive services from Indian health providers, you may see these providers without a referral.

What services require Prior Authorization?

To see which services require prior authorization, please refer to the Benefits Chart in the Evidence of Coverage (EOC). To view a plan's EOC, go to our Plan Materials and Forms page >  Expand section called "Evidence of Coverage" >  Find the plan > click your preferred language. You can download its EOC for more information.

What is the process for obtaining a Prior Authorization?

When a decision regarding the Prior Authorization or referral request is made, Health Net will provide its best interpretation of how the benefits and services can be applied to the your specific situation. Once this initial decision has been made (usually referred to as an Organization Determination), you will be informed as to whether the requested service will be provided or if payments will be made.

The Prior Authorization process for review and decision making of an Organization Determination may be made within a standard timeframe (typically made within 14 days) or it can be an "expedited" Organization Determination (typically made within 72 hours), based on your medical needs.

You, your provider, or your appointed representative may request an expedited decision if you or your provider believes waiting for a standard decision may seriously harm your health or ability to function. 

To request a standard decision, you, your doctor, or your appointed representative can initiate a written request for an Organization Determination. If your Prior Authorization request has been denied by Health Net, (usually referred to as an Adverse Organization Determination) you have the right to appeal this decision.

More Information

For more information about coverage determinations and prior authorization, you may refer to the sections of the Evidence of Coverage (EOC) for your plan listed below, or you may contact Member Services.

Plan Name Coverage Determinations EOC Section
All Health Net Healthy Heart (HMO), Health Net Seniority Plus Ruby (HMO) and Health Net Ruby Select (HMO),
Health Net Gold Select (HMO), Health Net Jade (HMO SNP)
Chapter 9, section 5
All Health Net Seniority Plus Amber (HMO SNP) plans Chapter 9, section 6
Health Net Green (HMO) Chapter 7, section 5

Appointing a Representative

Find out how to appoint a representative to act on your behalf. Visit the Appointing a Representative page.

Pharmacy Prior Authorization

Looking for Drug Coverage Determinations - Exceptions and Prior Authorizations? Visit the Coverage Determinations for Drugs - Exceptions and Prior Authorizations page.

Contact Information

Health Net of California 
Phone: 1-800-977-8226
FAX: 1-844-501-5713
Status of Auth: 1-800-977-7282
TTY: 711

April 1 - September 30*
Monday through Friday, 8:00 a.m. to 8:00 p.m.
October 1 - March 31**
7 days a week, 8:00 a.m. to 8:00 p.m.

* April 1 - September 30, calls on Saturdays, Sundays, and Federal holidays, with the exception of President's Day, will be handled by our automated phone system. 
** October 1 - March 31, calls on Thanksgiving and Christmas Day will be handled by our automated phone system.

To obtain a list of services that require prior authorization, please contact Member Services. Please note that all out of network requests require prior authorization except emergency care, out-of area urgent care, or out-of area dialysis.