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CommercialPrior AuthHigh impact

25-250 Refer Members to In-Network Providers to Minimize Out-of-Pocket Costs

Health Net·CA·Prior Authorization
Effective date
Not stated
We identified it
Jun 20, 2026
Days to comply
—

Summary

Health Net now requires prior authorization for all out-of-network referrals except for emergencies and legally mandated care. Providers must prioritize in-network referrals and contact Health Net Provider Services for authorization before referring patients out-of-network to avoid claim denials and patient out-of-pocket costs.

Action Required

Action needed
Immediately: Billing team must update referral workflow to require prior authorization verification before processing any out-of-network referrals. Front desk staff must use the Find a Provider tool to locate in-network providers first. Providers must contact appropriate Health Net Provider Services line (phone numbers provided in policy) to obtain prior authorization for out-of-network referrals except emergencies. Update encounter forms and EMR templates to remind staff of in-network priority requirement. Claims for unauthorized out-of-network referrals will not be reimbursed.

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