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Page 1: PRIOR AUTHORIZATION REQUIREMENTS PPO (Self Funded … · PRIOR AUTHORIZATION REQUIREMENTS PPO (Self Funded and Fully ... 977-7282 Prior Authorization Request Fax ... Prior authorization

PRIOR AUTHORIZATION REQUIREMENTS PPO (Self Funded and Fully Insured Plans)

Home Depot Employees

Implemented:01/01/2004 Prior Authorization Requirements Reviewed: 07/01/2005 Page 1 of 1

Prior Authorization Request Telephone Line – (800) 977-7282 Prior Authorization Request Fax Line – (800) 793-4473 (Elective); (800) 672-2135 (Urgent) Other Contact Information: Fax Line to submit Additional Clinical Information - (510) 287-4653 or (800) 440-4425 Provider Status/Member Eligibility & Benefits – www.healthnet.com or call (800) 641-7761 Note: In a PPO plan, the PPO provider is responsible for prior authorizing all in-network services that require authorization before treatment or surgery. Members are responsible for calling Health Net to prior authorize any out-of-network services listed. When Prior Authorization is Needed – The member or the provider should call Health Net to prior authorize medical treatment at least 14 days prior to any planned admission or inpatient surgery. To receive full benefits under the plan, the member or the provider must pre-certify the services and treatments listed below. The plan does not require prior authorization for lengths of stay 48 hours or less for normal childbirth nor for a length of stay 96 hours or less for Cesarean section deliveries. If the maternity stay exceeds these lengths of stay, prior authorization is required. In an Emergency – The member or the member’s family must notify Health Net within 48 hours of any hospital admission for an emergency. Prior authorization is not necessary in emergency situations if the member is not admitted to the hospital. Penalty for Not Prior Authorizing – If the member is using out-of-network providers and does not call Health Net to prior authorize a required medical treatment, the plan reduces the benefits by $500 per occurrence. Penalty amounts do not count toward the out-of-pocket maximum.

Services Requiring Prior Authorization • Behavioral health and substance abuse

treatment • Convalescent facilities • Extended care facilities • Home health care

• Hospice care • Inpatient hospital stays • Inpatient surgery • Private duty nursing • Transplants

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