Health net request for prior authorization form

Choosing Who Can See My Confidential Medical Information

© Copyright 2022 Health Net HMO and HSP health plans are offered by Health Net of California, Inc. Health Net EPO insurance plans, Policy Form #P34401, EnhancedCare PPO insurance plans, Policy Form #P35001, and PPO insurance plans, Policy Form #P30601, are underwritten by Health Net Life Insurance Company. Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. Covered California is a registered trademark of the State of California. All rights reserved.

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.

Choosing Who Can See My Confidential Medical Information

© Copyright 2022 Health Net of California, Inc., Health Net Life Insurance Company, and Health Net Community Solutions, Inc. (Health Net) are subsidiaries of Health Net, LLC. and Centene Corporation. Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. Health Net is a registered service mark of Health Net, LLC.

Services Requiring Prior Authorization – California

Please confirm the member's plan and group before choosing from the list below.

Providers should refer to the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI) to determine exclusions, limitations and benefit maximums that may apply to a particular procedure, medication, service, or supply.

Refer to the Pharmacy section of the website for information regarding prescription authorization requirements.

Prior Authorization Lists

• Cal MediConnect (PDF)
• Medi-Cal Fee-for-Service Health Net and CalViva Health (PDF)
  • Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, and Tulare counties
  • Fresno, Kings and Madera counties (CalViva Health)
• Commercial – California (PDF)
  • Direct Network HMO (including CommunityCare HMO) and Point of Service (POS) Tier 1
  • Health Care Service Plan (HSP)
  • Point of Service Tiers 2 and 3 (Elect, Select and Open Access)
  • CommunityCare HMO participating physician groups (PPGs)
  • EPO, PPO, out-of-state PPO and Flex Net
• Medicare – California (PDF)
  • Medicare Advantage (MA) PPO and HMO Direct Network
• Medi-Cal Los Angeles County Department of Human Services (LA-DHS) Participating Physician Groups (PDF)