How to submit PA requests (fax, phone, online) and attach records

Submit prior authorization (PA) requests to Health Net via fax, phone, or the online provider portal using the contact information on page 15. Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request.

• Send requests via fax, phone or online (provider.healthnetcalifornia.com).
• Include supporting documentation: medical records, treatment plans, test results, evidence of conservative treatment.

PA timelines and notification rules

Follow Health Net timelines: submit routine PA requests at least five business days before a scheduled procedure and urgent requests 72 hours before a scheduled procedure. Emergency services do not require PA; emergency hospitalizations require notification within 24 hours.

• Routine requests: ≥ five business days before procedure.
• Urgent requests: 72 hours before procedure.
• Elective services: submit as soon as need identified.
• Emergency services: no PA required; notify within 24 hours for hospital admissions.

Verify eligibility and confirm medical necessity

Verify member eligibility before providing care; a PA or approval from this list does not guarantee coverage — medical necessity must exist and the member's Evidence of Coverage (EOC) defines covered benefits.

• Providers must verify eligibility through the Provider Services Center prior to care.
• Authorization is subject to benefit plan coverage limitations and medical necessity.

When to notify versus obtain formal PA

Use notification when indicated (for example, emergency hospitalizations require notification to the Hospital Notification Unit within 24 hours) and obtain formal PA for services marked as requiring PA on the list.

• Emergency hospitalizations: notification required only within 24 hours to Hospital Notification Unit.
• Services marked with 'X' on the PA list require formal prior authorization.

PA required for outpatient medical‑benefit pharmaceuticals

Obtain prior authorization for outpatient pharmaceuticals administered under the medical benefit when listed on the drug list; PA requests for these drugs must be submitted to Health Net Pharmacy Services.

• Extensive list of outpatient medical‑benefit drugs (examples begin with Abrilada™, Adakveo®, Adcetris®, etc.) require PA.
• Refer PA requests for outpatient pharmaceuticals to Pharmacy Services as indicated.

Biosimilar substitution and PA requirements

When a biosimilar is available, the biosimilar (or preferred biosimilar) is required in lieu of the branded product and biosimilars require prior authorization; preferred biosimilars must be tried before non‑preferred approval and are authorized by Pharmacy Services.

• Preferred biosimilars are required in lieu of branded drugs and must be tried prior to non‑preferred approval.
• Biosimilars themselves require prior authorization and are authorized by Pharmacy Services.
• Examples and PA exceptions for specific agents (e.g., certain bevacizumab and filgrastim products) are noted in the drug list.

Authorization for CCS carve‑out services

For CCS‑eligible (carve‑out) services, obtain authorization through the California Children's Services (CCS) program; services must be provided by CCS‑paneled providers at CCS‑approved facilities and approved by CCS.

• CCS services require CCS program approval and must be delivered by CCS‑paneled providers at CCS‑approved facilities.
• Refer to the CCS enrollment/paneling information on the DHCS website if needed.

Sensitive/confidential services exempt from PA

Do not submit PA for specified sensitive and confidential services — these services (including minor consent services, family planning, sexual assault care, infectious disease diagnosis/treatment, STI testing/treatment, drug and alcohol treatment, and outpatient mental health) may be obtained from any qualified in‑network or out‑of‑network provider without prior authorization.

• Minor consent services (pregnancy‑related, family planning, sexual assault) and outpatient mental health for minors (where appropriate) do not require PA.
• Adult sensitive care services (family planning, HIV testing, abortion‑related services) do not require PA.

Hospice PA rules — inpatient requires PA; certain outpatient services exempt

Inpatient hospice care requires prior authorization under Health Net's standard PA processes; outpatient hospice routine home care, continuous home care, respite care, and hospice physician services do not require PA but required documentation must be submitted as directed.

• Inpatient hospice: attach required documentation and submit to Health Net Prior Authorization for approval.
• Outpatient hospice (routine home care, continuous home care, respite care, hospice physician services): PA is not required, but documentation submission is still required.

Hospice documentation required for authorization/continuation

For hospice authorization/continuation, submit required hospice documentation (e.g., Medi‑Cal Hospice Program Election form, written prescription justifying general inpatient level of care, copy of initial plan of care, face‑to‑face encounter documentation, and transfer summary when applicable) via the specified encrypted email address.

• Required items include: Medi‑Cal Hospice Program Election form; revocation of hospice election if applicable; copy of the written initial plan of care.
• Provide a written prescription signed by the attending physician that includes justification for general inpatient level of care.
• Provide a face‑to‑face encounter document verifying clinical evaluation for continued eligibility.
• Provide a transfer summary when the patient changes health plan carriers (refer to APL 25‑008).
• Submit required documentation via encrypted email to HospiceCTIforms@centene.com.

Basic prenatal care does not require PA

Do not obtain PA for basic prenatal care with a participating network obstetrician; this is listed as an example of services not requiring prior authorization.

• Basic prenatal care provided by a participating network obstetrician does not require prior authorization.

Partial list of services not requiring PA (preventive, prenatal, emergency, referrals)

Other services explicitly listed as not requiring prior authorization include preventive services from participating providers, services for emergency medical conditions, initial specialist referrals to participating specialists, urgently needed services when the member is outside their county, and services by a certified nurse midwife or participating OB/GYN.

• Preventive services from a participating provider: no PA required.
• Services for emergency medical conditions: no PA required; follow notification rules for hospital admissions.
• Initial referral to a participating specialist: no PA required.
• Urgently needed services outside the member's county: no PA required.
• Certified nurse midwife and OB/GYN services from participating providers: no PA required.

Biomarker testing (FDA‑approved, advanced/metastatic cancer)

FDA‑approved biomarker testing for insureds with advanced or metastatic (stage 3 or 4) cancer is listed in the limitations/exclusions context (noted as an item in the exclusions listing).

• Biomarker testing for advanced/metastatic stage 3 or 4 cancer (FDA approved) is referenced in the limitations/exclusions.

Documentation note: transfer summaries and face‑to‑face encounters (APL 25‑008)

Refer to APL 25‑008 for transfer summary requirements when a patient changes health plan carriers; face‑to‑face encounter documentation is required to verify clinical evaluation for continued hospice eligibility.

• Transfer summary requirement when patient changes carriers — see APL 25‑008 for details.
• Face‑to‑face encounter document verifies clinical evaluation for continued hospice eligibility.

General limitations and exclusions (items not subject to PA)

Limitations and exclusions that do not require prior authorization include emergency medical conditions, urgently needed services when the member is outside their county, specialist referrals (initial), services by participating certified nurse midwives/OB‑GYNs, MOA 638 Indian Health Service facilities, FDA‑approved biomarker testing for advanced/metastatic cancer, COVID‑19 diagnostic and screening testing, and services under the Children and Youth Behavioral Health Initiative fee schedule.

• Emergency medical conditions and urgently needed out‑of‑county services: excluded from PA.
• Certified nurse midwife and OB/GYN services from participating providers: excluded from PA.
• MOA 638 Indian Health Service facilities referenced as excluded.
• COVID‑19 diagnostic and screening testing: listed among limitations/exclusions.
• Children and Youth Behavioral Health Initiative fee schedule services: included in exclusions/limitations.

Primary prior authorization request contact

To submit a prior authorization request, call 888‑893‑1569, fax 800‑743‑1655, or submit online at provider.healthnetcalifornia.com.

• Primary prior authorization phone: 888‑893‑1569.
• Primary prior authorization fax: 800‑743‑1655.
• Online submission: provider.healthnetcalifornia.com.

Hospital, post‑stabilization and long‑term care contacts

For hospital notifications, post‑stabilization and long‑term care contacts use the Hospital Notification Unit at 800‑995‑7890 (fax: 800‑676‑7969) and the Long‑term Care Intake Line at 800‑453‑3033 (fax: 855‑851‑4563).

• Hospital Notification Unit/Post‑stabilization Notification phone: 800‑995‑7890; fax: 800‑676‑7969.
• Long‑term Care Intake Line phone: 800‑453‑3033; fax: 855‑851‑4563.

Behavioral health and transplant contact numbers

Behavioral Health Team inquiries: call 844‑966‑0298. Transplant Team fax contacts: 833‑581‑5908 and 833‑769‑1141.

• Behavioral Health Team: 844‑966‑0298.
• Transplant Team fax numbers: 833‑581‑5908 and 833‑769‑1141.

Specialty services contacts (advanced imaging, infusion)

For specialty services, contact Evolent Specialty Services for advanced and cardiac imaging at 800‑424‑4809 or submit online at www.radmd.com; Coram Specialty Infusion Services is the referenced preferred home‑infusion provider.

• Evolent (advanced and cardiac imaging): 800‑424‑4809; online submission via www.radmd.com.
• Coram Specialty Infusion Services referenced as preferred home/infusion provider.

Nurse advice line contact (24/7)

Use the 24/7 Nurse Advice Line for clinical triage and member clinical questions at 800‑675‑6110, available 24 hours a day, seven days a week.

• Nurse Advice Line: 800‑675‑6110 (24/7).