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 obtain a list of services that require prior authorization, please contact Member Services. Please note out-of-network/non- contracted providers are under no obligation to treat Wellcare By Health Net members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services

What is the process for obtaining a Prior Authorization?

You may request prior authorization by contacting Member Services. We recommend that providers submit prior authorizations through the web portal, via phone or via fax.

Decisions and notifications will be made no later than 72 hours after receipt for requests meeting the definition of Expedited (fast decision) and no later than 14 calendar days for requests meeting the definition for Standard. Allwell automatically expedites an organization determination if we find that your health, life, or ability to regain maximum function may be jeopardized by waiting for a standard determination. We will notify you of our decision either in writing or via telephone. In the case of an emergency, you do not need prior authorization.

Prior authorization is not a guarantee of payment. Wellcare By Health Net retains the right to review the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services.

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.