Health Net of California (a Centene company) is a DMHC-licensed plan whose HMO/POS products fall under California’s autism mandate; its PPO policies are written through Health Net Life Insurance Company. The headline for intake: Health Net "has decided to discontinue offering commercial group health plans in California." All small-business and large-group plans are affected, "Many commercial group policies are expected to end February 28, 2027," and "Prior authorizations issued by Health Net may not transfer to a new carrier." Medi-Cal, Ambetter (Covered California) and Medicare continue. Any employer-group Health Net family starting ABA now needs a plan for the switch.
Health Net now administers behavioral health itself — "Health Net manages inpatient and outpatient treatment for behavioral health" — and ABA requests go to the "Health Net Behavioral Health Autism Center" at ABA@healthnet.com or fax 855-427-4798 (BH provider services 844-966-0298). The front door is the Confirmation of Diagnosis form, completed by a physician or licensed psychologist with the most recent face-to-face evaluation; then the ABA PA form with the treatment plan, naming the case supervisor, proposed start and end dates and hours per code (97151–97158, 0362T/0373T, and H-codes). "Addendums to existing authorizations can no longer be accommodated": to change hours or dates, submit a new complete request with a letter explaining why, and the existing authorization "will be ended." For commercial ABA decisions, "the Council for Autism Services Providers ABA Professional Guidelines are used" — Health Net’s ABA-named clinical policies (CA.CP.BH.104/105) are Medi-Cal-only and do not apply to commercial members.[2][17][18][8][6][7]
One conflict to know: the PPO manual page (October 2025) still describes a notification model for the first six months, while the July 2026 commercial PA list marks ABA as PA-required for PPO too — treat PA as required. And the group exit: notices began September 1, 2026; ask every employer-group family for their plan end date and replacement carrier, because a new carrier means a new authorization.[2][17][18][8][6][7]
California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every plan covering hospital, medical or surgical care to cover "behavioral health treatment for pervasive developmental disorder or autism" — defined to include "applied behavior analysis and evidence-based behavior intervention programs" — "in the same manner and … subject to the same requirements" as mental health parity under § 1374.72. The statute has no age limit and no dollar or visit cap. Treatment must be "prescribed by a physician and surgeon" or "developed by a psychologist," follow a treatment plan with measurable goals "reviewed no less than once every six months" by the qualified autism service provider, and may not be used for "respite, daycare, or educational services." Plans may still use "case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing."[11][12][19][20][21][22]
Three newer layers matter at intake. SB 855 (§§ 1374.72, 1374.721; Ins. §§ 10144.5, 10144.52) requires medical-necessity decisions under "generally accepted standards," using the criteria of "the nonprofit professional association for the relevant clinical specialty," supplied "at no cost" — and bars limiting coverage because services "should be or could be covered by a public entitlement program, including … special education or an individualized education program, Medicaid." SB 402 (carrying AB 951) says a contract issued, amended or renewed on or after January 1, 2026 "shall not require an enrollee previously diagnosed with pervasive developmental disorder or autism to receive a rediagnosis to maintain coverage" and "shall not discontinue or delay existing treatment while waiting for a rediagnosis." And every plan must keep "an adequate network" of qualified autism service providers. Exempt: self-funded ERISA employer plans (outside state law), Medi-Cal plan contracts, specialized plans that do not deliver mental health services, and — for CDI policies — accident-only, specified-disease, hospital-indemnity and Medicare supplement policies.[11][12][19][20][21][22]
California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional (BCaBA-level behavior service providers under 17 CCR § 54342, or — since SB 805 — associate MFTs, ACSWs, APCCs and psychological associates) works under the provider’s supervision; and a QAS paraprofessional — the technician — is "an unlicensed and uncertified individual" supervised "at a level of clinical supervision that meets professionally recognized standards of practice." Health Net publishes no commercial ABA fee schedule; rates are negotiated in the provider agreement (contract questions: DNBHC@healthnet.com).[23][24][13][25]
Health Net does not publish an ABA-specific filing limit in the documents read; the number sits in the provider agreement. For Health Net’s DMHC-licensed products (its HMOs and any DMHC-regulated PPO/EPO), state regulation sets the floor: no claim deadline "less than 90 days for contracted providers and 180 days for non-contracted providers after the date of service"; payment of a complete claim within 30 calendar days of receipt since January 1, 2026, with 15% annual interest from day 31 (H&S § 1371 as amended by AB 3275; the regulation’s 30 and 45 working days no longer control); and at least 365 days from the plan’s action to file a provider dispute, which must be decided within 45 working days (28 CCR §§ 1300.71, 1300.71.38). CDI-regulated insurance policies are outside these DMHC rules but face the same 30-calendar-day payment clock under Ins. Code § 10123.13 since 2026; self-funded ERISA plans follow their plan documents.[1][26][27]
Continuity of care: Health Net lets new and existing members "continue with their existing out-of-network providers for up to 12 months" when criteria are met, and covers "Behavioral health conditions — all acute, serious or chronic mental health conditions, including treatment for children diagnosed with autism spectrum disorder (ASD). These services include applied behavioral analysis (ABA) — for up to 12 months." The provider must accept Health Net's rates and payment methods "unless a letter of agreement or letter of understanding is executed," and its utilization management; requests are decided within five business days (pendable 45 days for more information; three calendar days if urgent). A member may also ask to finish care with a provider who has left the network.[15][16]
HMO referrals out of network: a participating physician group "must refer members to participating providers except in emergencies or as otherwise required by law"; an out-of-network referral needs prior authorization, and "once Health Net authorizes a referral, the authorization cannot be withdrawn and payment is required for services rendered." Out-of-network providers "cannot refer the member to another out-of-network provider without authorization."[15][16]
The questions that decide whether a family can start with Health Net of California (commercial), and what they have to bring. Each maps onto something intake should ask on the first call.
No age limit. Health Net publishes no commercial ABA age cap (its under-21 ABA policies are Medi-Cal only), and H&S § 1374.73 / Ins. § 10144.51 contain none for fully insured plans.[6][11]
Health Net wants "a copy of the member’s most recent face-to-face evaluation" with the diagnosis form but sets no maximum age for it. Its manual restates the 2026 rule: a member "is not required to obtain a rediagnosis" to keep BHT coverage, and coverage "cannot be discontinued or delayed while waiting for a rediagnosis"; utilization review is still allowed.[6][5]
A physician or licensed psychologist: the diagnosis form "must be completed by a physician or licensed psychologist," recording the diagnosis date, whether ABA is recommended, and the signer’s license type and number. LCSW: no — the diagnosis form must be completed by a physician or licensed psychologist.[5]
No single instrument is mandated. The diagnosis form asks which tool confirmed it from a checklist — CHAT, M-CHAT/M-CHAT-R/F, STAT, SCQ, ASSQ, CAST, KADI, ADOS/ADOS-2, ADI-R, CARS/CARS-2, GARS-3, or "Other valid form of approved evidence-based assessment" — a list that mixes screeners with diagnostic instruments.[5]
No PCP referral: "Behavioral health services can be accessed directly by parents or by referral from any treating physician," and members may contact Health Net "without a referral from their primary care physician (PCP) or participating physician group (PPG)." The gate is the physician/psychologist diagnosis form (which records "ABA recommended: Yes/No") plus PA.[6][29]
Health Net’s direct-network PA page: "For HMO, allow five business days for routine … and 72 hours for expedited"; the PA list asks for routine requests "At least five calendar days before" service. That matches the DMHC floor, H&S § 1367.01(h) (5 business days from receipt of the information reasonably necessary; 72 hours urgent), and Ins. § 10123.135(h) for CDI policies. Self-funded groups follow 29 CFR 2560.503-1 (15 days pre-service, one 15-day extension, 72 hours urgent). Reauthorization: the PPO page says the provider must "review it once every six months," and continued care "after the initial six months" needs a new request.[31][3][32][7]
Health Net’s COB order: a plan without a COB provision pays first; the subscriber’s plan before the dependent’s; for a dependent child, the plan of the subscriber "whose birthday is earlier in a calendar year is the primary carrier" (including parents living together who never married, but not divorced or separated parents — for them a court decree, then custodial parent, stepparent, non-custodial parent; joint custody uses the birthday rule). "If one plan is an individual plan, not a group plan, both plans pay as primary. The payments do not coordinate." TRICARE/CHAMPVA: "The plan is primary in all instances when a member is covered by TRICARE or CHAMPVA." Medi-Cal pays last, and the plan may not limit coverage because a public program could pay (H&S § 1374.72(h)).[9][33][19]
No ABA-specific telehealth code list for commercial. Health Net’s general rule: POS 02 or 10 "accepted when used correctly," modifier 95 (synchronous) or GQ (asynchronous), payment parity, and no telehealth for services that "Require the in-person presence of the patient." Which ABA codes are approvable remotely is decided on the authorization.[30]
Ask the plan: Health Net Behavioral Health Autism Center (844-966-0298) — whether 97155/97156 (or 97153) by telehealth are approvable on this authorization.
Coverage decides whether Health Net of California (commercial) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
No commercial per-day cap is published; units are authorized as hours per week or month per code. At the claim level Health Net’s code-editing software applies the CMS National Correct Coding Initiative edits "for professional and facility claims," including "medically unlikely edits (MUE)" — the maximum units "a provider would bill under most circumstances for a single member, on a single date of service" — so the CMS practitioner MUE for each ABA code is the per-day ceiling to plan against.[4][28]
Centene policy CP.BH.500, listed on Health Net’s Commercial & Medi-Cal policy index (rev. April 2026), requires every behavioral health record entry to be "dated and signed/authenticated (including licensure and/or certification) by the rendering provider prior to submission of the claim," with "Exact start and stop times of the service"; "Billed units not fully supported by documentation may be subject to payment denial or recoupment."[10]
No commercial ratio is published. The PA form requires the "Case supervisor name and credentials" and NPI; the manual restates the statute (treatment administered by a QAS provider, a professional "employed and supervised by the QASP," or a supervised paraprofessional); and UM runs on CASP guidelines, which carry their own supervision recommendations.[4][6]
Ask the plan: Your Health Net provider agreement (DNBHC@healthnet.com) — any supervision ratio is a contract term.
No commercial setting restriction is published. Health Net "does not provide coverage for educational services (except for ABA services for Health Net commercial members diagnosed with ASDs when coverage is mandated by the state)"; the statute bars limiting coverage because services could be covered by "special education or an individualized education program" (§ 1374.72(h)). Home, clinic or community settings are approved per the treatment plan.[6][19]
Ask the plan: Ask on the PA whether school-setting hours are approvable for this member.
Not published for commercial members; do not borrow the Medi-Cal policies CA.CP.BH.104/105.[8]
Ask the plan: Health Net BH Provider Services 844-966-0298, or Health Net payment policies for code-pair edits.
The PA form collects the group’s name and TIN plus the case supervisor’s NPI; the statute requires QAS professionals and paraprofessionals to be employed by the QAS provider or an entity employing them. Health Net publishes no rule on whether the technician or the supervising BCBA is the rendering provider on 97153.[4][24]
Ask the plan: Your Health Net provider agreement or BH Provider Services 844-966-0298.
Often, for up to 12 months: Health Net's continuity-of-care rules list ABA for children with autism among covered behavioral health conditions, if the provider accepts Health Net's rates (or signs a letter of agreement) and its utilization management. Health Net decides within five business days.
Yes — for ASD under California’s mandate, with prior authorization through the Health Net Behavioral Health Autism Center (ABA@healthnet.com, fax 855-427-4798).
Its commercial employer-group business is: many group plans are expected to end February 28, 2027, and Health Net says its prior authorizations "may not transfer" to the new carrier. Medi-Cal, Ambetter (Covered California) and Medicare continue.
Not by addendum. Health Net requires a new, complete PA request covering all codes, with a letter explaining the clinical reason; the existing authorization is ended.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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