Post-Stabilization Care

Post-stabilization care services means covered services, related to an emergency medical condition, that are provided after an member is stabilized in order to maintain the stabilized condition, or under some circumstances, to improve or resolve the condition. Health Net and its delegated participating physician groups (PPGs):

• Are financially responsible for post-stabilization care services obtained in or outside the Health Net service area that are authorized by a Health Net representative, including Health Net's delegated PPGs.
• Are financially responsible for post-stabilization care services obtained in or outside the Health Net service area or provider network that are not authorized by a Health Net representative, including Health Net's delegated PPGs, but administered to maintain the member's stabilized condition within one hour of a request to Health Net or Health Net's delegated PPG for authorization of further post-stabilization care services.
• Are financially responsible for post-stabilization care services obtained in or outside of Health Net's service area or PPG network that are not authorized by a Health Net representative, including Health Net's delegated PPGs, but administered to maintain, improve or resolve the member's stabilized condition if:
  • Health Net or its delegated PPG does not respond to a request for authorization within one hour.
  • Health Net or its delegated PPG cannot be contacted.
  • Health Net or its delegated PPG representative and the treating physician cannot reach an agreement concerning the member's care and the PPG physician is not available for consultation. In this situation, the delegated PPG must give the treating physician the opportunity to consult with a PPG physician and the treating physician may continue with care of the patient until the PPG physician is reached or one of the criteria listed below is met; and there is a limit to the charges to members for post-stabilization care services to an amount no greater than what Health Net would charge the member if he or she had obtained the services through the network. For purposes of cost-sharing, post-stabilization care services begin upon inpatient admission.

End of Financial Responsibility

Health Net or its delegated PPG's financial responsibility for post-stabilization care services that has not been authorized ends when:

• A PPG physician with privileges at the treating hospital assumes responsibility for the member's care.
• A PPG physician assumes responsibility for the member's care through transfer.
• The delegated PPG physician and treating physician reach an agreement concerning the member's care.
• The member is discharged.