Prior Authorization for Medical Services and Organization Determination
Prior Authorization for Medical Services
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.
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 Medicare Advantage Plans page > Select a plan type > find the desired plan > click "View Details". You can download its EOC for more information.
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 an expedited decision, contact Customer Service.
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 contact Customer Service.
| Plan Name | Coverage Determinations EOC Section |
|---|---|
| All Health Net Healthy Heart (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Ruby Select (HMO), Health Net Gold Select (HMO), Health Net Jade (HMO SNP), and Health Net Violet (PPO) plans |
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
Need to appoint a representative to act on your behalf?
Pharmacy Prior Authorization
Looking for Drug Coverage Determinations - Exceptions and Prior Authorizations?
Contact information
Health Net of California
Phone: 1-800-977-7282
Fax: 1-800-793-4473; 1-800-672-2135
Status of Auth: 1-800-977-7282