Understanding Health Net Prior Authorization and Approval

Health Net requires prior authorization for certain medical services and treatments. This means that you need to get approval from Health Net before receiving these services.

Prior authorization is typically required for services that are not medically necessary or are considered experimental. This includes procedures like bone marrow transplants and experimental cancer treatments.

To get prior authorization, you'll need to submit a request to Health Net. This can be done by your doctor or other healthcare provider.

To initiate a prior authorization request, you have a few options. You can call the Pharmacy Services call center at 1-800-537-8862 to request an override for early refill denials. The call center is available between 8 AM and 4:30 PM Monday through Friday.

You'll need to provide clinical documentation supporting the medical necessity of the prescription, which can be faxed to 717-265-8289. Alternatively, you can initiate a request by fax using the prior authorization fax form downloaded from the Pharmacy Services Prior Authorization Fax Forms website. The completed form and supporting documentation should be faxed to 1-866-327-0191.

The basic information required for the prior authorization request includes the beneficiary's name and Medical Assistance ID number, the prescriber's contact information, and the specifics of the prescription. Here's a breakdown of the required information:

When it comes to initiating a prior authorization request, there are specific individuals who can take the lead. The prescribing provider must initiate a prior authorization request, except for early refill requests.

Pharmacies can request an override for early refill denials by calling the Pharmacy Services call center at 1-800-537-8862.

If you prefer to initiate a prior authorization request over the phone, you can call the Pharmacy Services call center at 1-800-537-8862. This is available Monday through Friday between 8 AM and 4:30 PM.

The Pharmacy Services coordinator will provide you with the fax number to submit your clinical documentation, which is 717-265-8289. This fax number is also provided during the phone call.

Filling prescriptions for certain conditions requires prior authorization. This includes prescriptions for non-preferred drugs, as indicated on the Preferred Drug List (PDL).

To determine if a prescription requires prior authorization, check the PDL for the list of drug classes and preferred/non-preferred drugs within each class. For example, Beta Blockers and VMAT2 Inhibitors are included in the PDL.

Prescriptions for preferred drugs may also require prior authorization if they meet specific criteria outlined in the Prior Authorization Clinical Guidelines. These guidelines relate to the corresponding PDL class of drugs.

Prescriptions for certain drugs not included in the PDL, such as Synagis, Alpha-1 Proteinase Inhibitors, and Immune Globulins, require prior authorization. Refer to the Prior Authorization Clinical Guidelines for specific requirements.

If a prescription exceeds the quantity limit, daily dose limit, or duration of therapy limit established by the Department of Human Services, prior authorization is required. Check the Quantity Limits/Daily Dose Limits for the list of affected drugs.

In some cases, multisource brand name drugs with an FDA-approved A-rated generic equivalent available for substitution require prior authorization, unless designated as preferred on the PDL.

Prescriptions for beneficiaries of a certain age may require prior authorization due to age restrictions. Check the Prior Authorization Clinical Guidelines for applicable age restrictions and requirements.

Therapeutic duplication, where a drug has the same mechanism of action as another recently received by the beneficiary, may also require prior authorization. Refer to the Prior Authorization Clinical Guidelines for specific requirements.

Early refills, defined as a request for a refill when more than 15% of a previous fill should remain, require prior authorization.

The prior authorization process involves a thorough review of the request to determine medical necessity. This review is typically conducted by a prior authorization personnel who applies the Prior Authorization Clinical Guidelines to assess the request.

If the reviewer determines that the request meets the guidelines, they will prior authorize the prescription. However, if the reviewer is unable to determine medical necessity or if the request does not meet the guidelines, the request will be referred to a physician reviewer for a medical necessity determination.

A physician reviewer may request additional documentation from the beneficiary's medical record to assess medical necessity. The reviewer's professional judgment is used to determine whether the services are medically necessary to meet the medical needs of the beneficiary.

Here is a summary of the review process:

To submit a prior authorization request, you'll need to follow the right steps. For requests initiated by phone, the prescribing provider must submit supporting clinical documentation by fax to 717-265-8289, which will also be provided by the Pharmacy Services coordinator.

The fax number for prior authorization requests initiated by fax is 1-866-327-0191. This number is also printed on the top of each prior authorization fax form.

If you prefer to initiate a request by fax, you can download the appropriate prior authorization fax form from the Pharmacy Services Prior Authorization Fax Forms website. Alternatively, you can call the Pharmacy Services call center at 1-800-537-8862 to request the form, which will be faxed to your office.

To submit the request, you'll need to fill out the completed, signed, and dated prior authorization fax form and include the required supporting clinical documentation of medical necessity.

The clinical review process is a crucial step in the submission and review process. Prior authorization personnel review requests for prior authorization and apply the Prior Authorization Clinical Guidelines to assess medical necessity.

If a request meets the guidelines, the reviewer will prior authorize the prescription. The reviewer may request additional documentation from the beneficiary's medical record to assess medical necessity.

If a reviewer can't determine medical necessity or if a request doesn't meet the guidelines, the prior authorization request is referred to a physician reviewer for a medical necessity determination. The physician reviewer may also request additional documentation.

In the professional judgment of the physician reviewer, a prior authorization request may be approved if the services are medically necessary to meet the medical needs of the beneficiary.

Automated Prior Authorization Approvals are available for prescriptions that require prior authorization.

The Department's Point-of-Sale On-Line Claims Adjudication System verifies a record of a paid claim(s) to determine medical necessity.

This verification process allows for automatic approval of prescriptions that meet the established guidelines.

The quantity limit established by the Department must be met for automated approval to occur.

The Department will notify you by return telephone call or fax whether your request for prior authorization is approved or denied, and will also send a written notice to your prescribing provider and you by mail.

You have the right to appeal the Department's decision if your request is denied or approved other than as requested.

The appeal process must be submitted in writing to the address listed on the notice within 30 days of the date of the prior authorization notice.

If you've been receiving a drug that's being reduced, changed, or denied, and you hand-deliver or postmark your appeal within 10 days of the notice, the Department will authorize the prescription until a decision is made on the appeal.

You have control over your healthcare decisions with Health Net's Prior Authorization process. You, your representative, or your network Primary Care Provider (PCP) can request a Prior Authorization for certain medical services.

You may not need a referral from your network PCP for emergency care, urgently needed care, kidney dialysis services, or to see a women's health specialist. If you're eligible for services from Indian health providers, you can see these providers without a referral.

The Benefits Chart in the Evidence of Coverage (EOC) will tell you which services require prior authorization. You can view a plan's EOC on Health Net's website by selecting a plan type and clicking "View Details".

Health Net will provide its best interpretation of how benefits and services apply to your situation after making a decision on your Prior Authorization or referral request. You'll be informed whether the requested service will be provided or if payments will be made.

You can 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.