Frequently Asked Questions

To get the full benefit of your health plan, it's important that you use providers (doctors, specialists, hospitals, etc.) that are in your plan's network when possible. To locate the provider network your plan uses, look at your member ID card or log in to your online account. You have an Individual & Family plan, and your plan name includes one of these network names:

• Ambetter HMO
• Ambetter PPO

You can select Find a Doctor while you are logged in to your account. Or, if you know your plan name/network, there’s no need to log in; you can simply select Find a Doctor on our home page. Enter the applicable fields in the Search tool and locate your plan’s provider network. You can search for a provider by name, provider ID or license number. You can also use the filters to narrow the type of provider you are looking for.

To change your PCP, log in to your online account and click Select/Change PCP. You will need to search Find a Doctor to make sure the PCP is in your provider network and to get their provider enrollment ID. Please allow 10 days for your account to be updated. You will also receive a new ID card with the name of your selected PCP in approximately 12 to 15 days.

In-network

In-network providers include doctors, hospitals and other health care providers that are contracted with Health Net to provide health care services within your plan's health care network. If you have an Ambetter HMO plan, you must use in-network providers (except for emergency or urgent care and services approved by Health Net).

Out-of-network

Out-of-network providers are doctors, hospitals and other health care providers who are not contracted with Health Net for the plan you selected. If you have an Ambetter PPO plan, you have the option of using out-of-network providers; however, if you use an out-of-network provider, your out-of-pocket costs are usually higher. In addition, doctors, specialists, and hospitals that are not in the network ordinarily can bill you the balance between what they charge and what Health Net pays, with some exceptions for services provided at certain types of in-network facilities.

A specialist is a doctor you see for certain types of health conditions. There are many types of specialists, including cardiologists, oncologists and orthopedic surgeons.

Some Health Net plans allow you to access specialists directly, while others may require your primary care physician (PCP) to give you a specialist referral. Check your plan document for details on how to get care from a specialist on your specific plan.

Typically, a referral is a request from your PCP for you to see a specialist. Depending on your plan, you may need a referral before you can see a specialist. Health Net may need to approve your referral before your specialist visit. This is called a "prior authorization."

Examples of referrals can be to an orthopedic surgeon for a back injury, or to a cardiologist for a heart condition.

You may need to get approval from Health Net before you can get certain heath care services. This process is called getting "prior authorization." Prior Authorizations are commonly submitted by your provider on your behalf. It is less common for you to submit a prior authorization request yourself.

You can learn more about prior authorization in your plan coverage documents or by calling us.

Prior Authorizations have specific time limits that vary based on the type of plan you have and the care needed. Your doctor can submit your prior authorization to us the same day as your medical appointment but sometimes it takes them some time. If all the information is provided, you should get a decision between 5-14 business days. If additional information is needed then that timeline can be extended 14-45 more days. Within 2 business days of the determination, we will notify you and your doctor in writing about the prior authorization.

You can learn more about prior authorization in your plan coverage documents or by calling us.

The prior authorization decision letter you receive in the mail will include an explanation about why your prior authorization was denied. A prior authorization may be denied for a variety of reasons, such as not enough information or lack of medical necessity. Please refer to your decision letter if your prior authorization was denied and work with your doctor or specialist about other care options or next steps.

The Health Net Member portal can be accessed by logging onto the Member section of this website. There you will find the tools you need to manage your health including: enrolling in automatic bill pay, sending secure messaging, printing a temporary Health Net ID card, and much more! If you are trying to access your account for the first time, you will need to register.