Coverage Explanation

Overview

Participating physician groups (PPGs) are responsible for providing or coordinating all professional services to members, including care among participating and non-participating providers. A referral is required for care that is beyond the primary care physician's (PCP's) or the PPG's scope of practice.

Listed below are examples of services that are referred for specialty consultation. This list provides guidelines and is not intended to be all-inclusive or indicate specific benefit coverage.

• Cardiology - Complicated hypertension (failure to respond or adverse response to conventional therapy)
• Endocrinology - Diabetic complications, including retinopathy and nephropathy
• Gastroenterology - Polyps or other abnormalities
• Behavioral health services - Diagnosis, treatment and consultation regarding management of clearly emotional issues for which the member or PCP feels the need for consultation (behavioral health services should be coordinated with medical services)
• Neurology - Seizures that are recurrent or refractory to treatment
• Rheumatology - Collagen vascular diseases depending on the extent and severity of manifestations or complications
• Pulmonology - Percutaneous lung biopsies
• Urology/nephrology - Prostate suspicious for malignancy or obstructive symptoms that may lead to surgical treatment

PPGs must do the following when making a referral:

• Transmit necessary information to the provider receiving the referral and vice-versa
• Request information from other treating providers as necessary to provide care
• Transfer a member's complete medical records to the new PCP in a timely manner (when the member chooses a new PCP with the network)
• For specialty providers, PPGs must ensure that all participating providers and non-participating specialty providers are informed of the prior authorization and referral process at the time of referral

Self-Referral Services

Members may self-refer for the following services without prior authorization:

• PCP visits
• Emergency services
• Urgently needed services from network providers
• Urgently needed care from out-of-network providers when the member cannot get to network providers (for example, when the member is outside of the plan's service area)
• Urgently needed services when outside of the county
• Family planning services
• Preventive services
• Sexually transmitted infection (STI) services
• HIV testing
• Pregnancy termination
• Basic prenatal care from a doctor that works with Health Net, unless the member has been receiving prenatal care from another doctor
• Services provided by in-network certified nurse midwives or obstetricians/gynecologists (OB/GYN)

In an emergency, members do not need a referral or approval from their PCP or Health Net before they seek care.

PCPs must be prepared to help members access urgently needed care, as necessary.

Members may obtain family planning and STI testing services from any health care provider licensed to provide these services. The member does not need PCP approval for these services.

Limitations on Member Liability

If the member obtains care from a non-participating provider (a provider who is not in Health Net's network or who is not approved for continuity of care), the provider may bill the member and the member may have to pay for services received, except for those listed above. If a member receives care from a non-participating provider, Health Net and its delegated PPGs must advise the member and provider that the member has received care from an out-of-network provider that would not otherwise be covered at an in-network level.

Health Net and its delegated PPGs must ensure that Cal MediConnect members are not responsible for the following covered services for which:

• The state does not pay Health Net.
• Health Net does not pay the individual or health care provider that furnishes the services under a contract, referral or other arrangement.
• Payments for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the member would owe if Health Net provided the services directly.

Prior Authorization and Review Rules

Prior authorization rules and other review requirements must be met in order to ensure payment for services. For Medicare benefits, in cases where a non-participating provider submits a bill directly to the member, the member should not pay the bill, but submit it to Health Net for processing and determination of member liability, if any.

For additional information regarding prior authorizations, refer to the Prior Authorizations topic. For additional information regarding medical records, refer to the Medical Records topic.