Notification of Hospital Admissions
- Participating Physician Groups (PPG)
(does not apply to HSP)
Hospitals are required to report any Health Net member's, including Individual Family Plan (IFP) Ambetter HMO and Ambetter PPO members inpatient admissions within 24 hours (or one business day when an admission occurs on a weekend or holiday), seven days a week to the Hospital Notification Unit. Failure to notify according to the requirements in the Provider Participation Agreement (PPA) may result in a denial of payment.
On receipt of admission notification, Health Net creates a tracking number and provides it to the reporting party. The tracking number is not, by itself, an authorization that services are covered under a member's benefit plan. Any services authorized by Health Net at the time of notification or thereafter are noted in the Health Net notification system. The tracking number is also transferred electronically to the Health Net claims processing system. To report a Health Net member inpatient admission, contact the Health Net Hospital Notification Unit.
Notification of after-hours admissions may be made by phone (the information is recorded by voicemail), fax, or web. On the next business day, a Health Net representative verifies eligibility, obtains information regarding the admission and, if applicable, provides a tracking number for the case.
When reporting inpatient admissions, the following information must be provided:
- Member name.
- Subscriber identification (ID) number.
- Attending and admitting physicians' first name, last name and contact information.
- Admission date and time of admission.
- Admission type (such as emergency room, elective or urgent).
- Facility name and contact information.
- Level of care.
- Admitting diagnosis code.
- CPT procedure code, if available.
- Facility medical record number.
- Participating physician group (PPG) authorization number (if applicable).
- For obstetrical (OB) delivery admissions, include newborn sex, weight, apgar score, time of birth, and medical record number.
- Discharge date, if applicable.
- Other insurance information, if applicable.
Timely notification of Health Net member inpatient admissions assists with timely payment of claims, reduces retroactive admission reviews and enables Health Net to concurrently monitor member progress. Health Net requires hospitals to notify the Hospital Notification Unit and the PPG (if applicable) or provider of a member's inpatient admission within 24 hours (or one business day when an admission occurs on a weekend or holiday) for the following services:
- All inpatient hospitalizations.
- Skilled nursing facility (SNF) admissions.
- Inpatient rehabilitation admissions.
- Inpatient hospice services.
- Emergency room admissions.
Electronic medical records or administrative system
In accordance with the Provider Participating Agreement (PPA) and Federal regulation 42 CFR 482.24 section (d) , hospitals and facilities must ensure compliance and prompt electronic notification of patient discharges and transfers. The following organizations have been designated as qualified health information organizations (QHIOs) and are available to assist with Data Exchange Framework (DxF) requirements:
- Los Angeles Network for Enhanced Services (LANES)
- Manifest MedEx
- SacValley MedShare
- San Diego Health Connect
- Applied Research Works, Inc.
- Health Gorilla, Inc.
- Long Health, Inc.
- Orange County Partners in Health-Health Information Exchange (OCPH-HIE)
- Serving Communities Health Information Organization (SCHIO)
Requests for Authorization for Post-Stabilization Care at Non-Participating and Participating Hospitals
Health Net is responsible for the coverage and payment of emergency services and post-stabilization care services to the provider that furnishes the services. This can be a participating provider, subcontractor, downstream subcontractor, or nonparticipating provider.
Requests for post-stabilization authorization
When a member is stabilized after emergency services but needs continued care before safely being discharged or transferred, the health care provider must request an authorization for post-stabilization care. The request must clearly state that the patient has been stabilized and the hospital is requesting authorization for post-stabilization care. Notification to Health Net of emergency room treatment or admission does not satisfy the requirement. Notification of admission for inpatient care does not satisfy the requirement. Post-stabilization requirements do not apply if the member has not been stabilized after emergency services and requires medically necessary continued stabilizing care.
Response time to requests
Health Net must approve or disapprove a request for post-stabilization care within 30 minutes. The post-stabilization care must be medically necessary for covered medical care. If the response to approve or disapprove the request is not given within 30 minutes, the post-stabilization care request is authorized. This applies to a participating provider, subcontractor, downstream subcontractor, or nonparticipating provider.
All requests for authorization, and responses to requests, must be documented. The documentation must include, but is not limited to:
- Date and time of the request.
- Name of the provider making the request.
- Name of the Health Net representative responding to the request.
Conditions of financial responsibility
Health Net is financially responsible for post-stabilization care services that are not pre-authorized, but are administered to maintain, improve, or resolve the member’s stabilized condition if the Plan:
- Does not approve or disapprove a request for post-stabilization care within 30 minutes.
- Cannot be contacted.
- Is unable to reach an agreement with the treating provider concerning the member’s care and a Plan physician is not available for consultation.
If this situation applies, the Plan must give the treating provider the opportunity to consult with a Plan physician. The treating provider may continue with care of the member until a Plan physician is reached or one of the following criteria is met:
- A Plan physician with privileges at the treating provider’s hospital assumes responsibility for the member’s care;
- A Plan physician assumes responsibility for the member’s care through transfer;
- The Plan and the treating provider reach an agreement concerning the member’s care; or
- The member is discharged.
A request for authorization for post-stabilization care can be made to the Hospital Notification Unit. Hospitals are required to provide Health Net with the treating physician and surgeon’s diagnosis and any other relevant information reasonably necessary for Health Net to make a decision to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer.
A hospital’s contact with the patient’s participating physician group (PPG) to request authorization to provide post-stabilization care does not satisfy the requirements of the above laws. Hospitals and other providers may not contact the patient’s PPG for authorization for post-stabilization care.