MedicaidPrior AuthHigh impact
24-340 Follow These Guidelines When Requesting a Peer-to-Peer Review With a Medical Director to Discuss An Adverse Determination
Health Net·CA·Prior Authorization
We identified it
Jun 20, 2026
Summary
New guidelines establish specific procedures for requesting peer-to-peer reviews with medical directors following adverse prior authorization determinations. Key restrictions include a 5 business day deadline, no P2P reviews after appeals are filed, and no post-discharge reviews for concurrent determinations.
Action Required
Immediately: Train all staff on new P2P review process - must call 818-676-5503 within 5 business days of adverse prior auth determination with member name, DOB, case number, medical director name, nurse name, and member ID. Update workflow to request P2P before patient discharge for concurrent reviews and before filing any appeals. Post phone number and required information list at all prior auth workstations.