- Participating Physician Groups (PPG)
Health Net follows Medicare guidelines for urgent care services and all benefit determinations unless the member's Cal MediConnect Member Handbook explicitly states otherwise.
Definition of Urgent Care
In accordance with federal guidelines, urgent care is defined as services required to prevent serious deterioration of health following the onset of an unforeseen condition or injury (such as sore throat, fever, minor lacerations, and some broken bones); medical services that require attention promptly to prevent impairment of health due to symptoms that do not constitute an emergency medical condition, but that are the result of an unforeseen illness, injury or condition for which medical services are immediately required. Urgent care is appropriately provided in a clinic, physician's office or in a hospital emergency department if a clinic or physician's office is inaccessible. Urgent care does not include primary care services or services provided to treat an emergency medical condition.
Access to Urgent and Emergency Care
When possible, urgent and emergency care must be provided by the primary care physician (PCP), on-call designee or contracting urgent care center. The member must be transferred to an urgent care center or hospital emergency room if medically necessary. The PCP or on-call physician designee is required to be available 24 hours per day, seven days per week. When the member is outside the service area and cannot obtain care from a network provider, Health Net covers urgent and emergency care rendered by any provider.