Notification of Hospital Admissions
- Participating Physician Groups (PPG)
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 the following facilities to notify BOTH Health Net Hospital Notification Unit AND the PPG or provider of a member's inpatient admission within 24 hours or one business day when an admission occurs on a weekend for the following services:
- All inpatient hospitalizations.
- Skilled nursing facility (SNF) admissions.
- Inpatient rehabilitation admissions.
- Inpatient hospice services.
- Emergency room admissions.
Hospitals are required to report any Health Net member's inpatient admissions (including Individual Family Plan (IFP) within 24 hours or one business day when an admission occurs on a weekend. To report an admission, contact the Health Net Hospital Notification Unit. Failure to notify according to requirements in the Provider Participation Agreement (PPA) may result in a denial of payment.
Inpatient admissions may be reported by fax, 24 hours a day, seven days a week. A Health Net representative verifies eligibility, obtains information regarding the admission, and, if applicable, provides a tracking number for the claim.
When reporting inpatient admissions, providers must have the following information:
- 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.
- 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.
On receipt of admission notification, authorized services are entered into the Health Net's notification system and a tracking number is created and provided to the reporting party. The tracking number is also transferred electronically to the Health Net claims processing system.
The tracking number is not an authorization that services are covered under a member's benefit plan.
Telephone coverage is provided 24 hours a day, seven days a week for non-participating facilities reporting post-stabilization. Note: plans for which Department of Managed Health Care (DMHC) provides oversight (HMO, POS, Elect, Elect Open Access) have telephone coverage 24 hours a day, seven days a week for non-participating facility requests for prior authorization of services for patients deemed stabilized.
Per the State Medicaid Agency Contract (SMAC) with Department of Health Care Services (DHCS) contracted hospitals and SNFs must use one of the following methods, in a timely manner, to inform the member’s D-SNP and the Medi-Cal plan of any hospital or SNF admission, transfer or discharge. Hospitals and SNFs must use either:
- A secure email or data exchange through a Health Information Organization or,
- An electronic process approved by DHCS.
This information must be shared to the extent allowed, under applicable federal and state law and regulations, and not be inconsistent with the member's expressed privacy preferences.
Must notify the D-SNP member’s MCP either immediately prior to, or at the time of, the member’s discharge or transfer from the hospital’s inpatient services, if applicable.
Must notify the D-SNP member’s MCP within 48 hours after any SNF admission.
For discharges or transfers, SNFs must notify the D-SNP member’s MCP in advance if possible, or at the time of the member’s discharge or transfer from the SNF
Facilities can identify the member’s Medi-Cal plan by using the State online eligibility system (AEVS).