Frequently Asked Questions
In our continued commitment to do our part to serve you better, we've provided answers to your most important questions. Please bookmark this page for easy reference.
Access services
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.
Maintain (or update) coverage and account
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.
Referral and Prior Authorization Process
Please note: This general information may not apply to all Health Net plan types. To learn more about your plan benefits, please review your plan documents.
Sometimes, you may need care that your primary care physician (PCP) can't provide. When this happens, you will be referred to a specialist or other healthcare provider to receive proper care. A specialist is a doctor who treats certain types of health conditions. For instance:
- An orthopedic surgeon treats broken bones
- An allergist treats allergies
- A cardiologist treats heart problems
These are just a few of many types of specialists.
Some Health Net plans allow you to visit a specialist without a referral. Check your plan for details on how to get care from a specialist.
A referral is a request from your PCP for you to see a specialist. Based on your plan, you may need a referral before you can visit a specialist. Health Net may need to approve your referral before your specialist visit. This is called a "prior authorization."
You may need to get approval from Health Net before you can get certain healthcare services. This process is called "prior authorization." This request is commonly sent by your provider on your behalf. It's less common for you to submit a prior authorization request yourself.
Learn more about prior authorization in your plan documents or by calling us.
Prior authorizations have time limits. They vary based on the type of plan you have and the care you need. Your doctor can even submit your prior authorization to us the same day as your medical appointment.
If all the information is given, you will get a decision within five business days. If we can't decide in that time, we'll let your doctor know that more time is needed. This would happen if:
- More information is needed
- Your request requires a consultation by an expert
- More testing is needed
Once we have all the required information to decide about the prior authorization, you'll get an answer within five business days. And we'll alert you and your doctor in writing within two business days of our decision.
If your condition is a serious threat to your health and may cause a loss of life, limb or a major bodily function your doctor can file a faster prior authorization request. If this occurs, you will get a decision within 72 hours – as long as all needed information is received.
Learn more about prior authorization in your plan documents or by calling us.
If denied, the prior authorization decision letter you receive in the mail will include the reason why your prior authorization was denied.
A prior authorization may be denied for a many reasons, such as:
- Not enough information
- Lack of medical need
- Not a covered benefit and more
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. If you or your doctor don't agree with the decision, you can file an appeal with us as explained in the denial letter.
Additional support and resources
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.