PPGs' Responsibilities for Authorization

Selected specialty and outpatient services that cannot be provided in a primary care physician's (PCP's) or specialist's office require prior authorization as outlined on the Prior Authorization Requirement for Cal MediConnect Product list (PDF).

Delegated participating physician groups (PPGs) perform the initial utilization review and authorization, while Health Net Medical Management staff conduct utilization review and authorization for select services that are provided by delegated providers. Health Net is jointly responsible with the PPG for such functions when services are covered under shared-risk agreements.

Each PPG is responsible for:

• Contracting or arranging with licensed and certified providers for a full range of primary and specialty care services, as well as with key ancillary and subspecialty providers, such as psychologists, family counselors, social workers, chiropractors, podiatrists, audiologists, and physical therapists
• Submitting copies of all referrals to Health Net for review and approval
• Monitoring the quality of care and the cost associated with services based on referrals to nonparticipating providers
• Obtaining encounter data from each referred physician
• Assuring timely payment to referred providers for covered services

Cal MediConnect delegated PPGs have five business days from receipt of the information reasonably necessary to render a decision in accordance with Health and Safety Code Section 1367.01, but no longer than 14 calendar days from the receipt of the request. For expedited service authorizations, where the provider indicates or Health Net determines that following the standard time frame could seriously jeopardize the member's life or health or ability to attain, maintain or regain maximum function, delegated PPGs must make a decision and provide notice as expeditiously as the member's health condition requires and no later than 72 hours after the receipt of the request for service.

The decision may be deferred and the time limit extended an additional 14 calendar days only where the member or the member's provider requests an extension, or Health Net can provide justification upon request by the Department of Health Care Services (DHCS) or the Centers for Medicare and Medicaid Services (CMS) for the need for additional information and how the extension is in the member's interest. The need for additional information must likely lead to approval of the request. Such information is expected to be received within 14 calendar days. Any decision delayed beyond the time limit is considered a denial and must be immediately processed as such.

PPGs are responsible for using the following guidelines when authorizing services:

• Records of authorized services - The PPG must keep records of all authorized member services. This allows the PPG to monitor utilization of services by participating physicians and to compare the PPG records to the monthly reports provided by Health Net. Refer to the Medical Data Management Reporting discussion for additional information
• PPGs may not withdraw authorization after services are provided or when a member acts against medical advice - After a PPG authorizes a hospitalization, authorization cannot be withdrawn or payment denied because the member refuses to follow the directions of the attending physician. An example is a member self-discharging from the hospital against the attending physician's medical advice. Refer to the conditions for transfer between PPGs under the Enrollment topic for additional information