Inpatient Services and Skilled Nursing Facility Admissions

Inpatient Services

Inpatient services are covered on all Health Net plans. Services are covered with unlimited days per admission, subject to benefit calendar year maximums if applicable. Specifics regarding inpatient services are as follows:

• Inpatient services in a hospital, when medically necessary, are covered, subject to the scheduled copayments or coinsurance.
• Elective hospitalization of Health Net members is authorized by the participating physician group (PPG) if the member is affiliated with a capitated PPG that has responsibility for prudent hospital use. Services can be in an acute, general or specialized care hospital.
• Participating providers must contact Health Net or a Payor and the appropriate primary care physician (PCP) or PPG within 24 hours or by the next business day after a member is admitted into a hospital. Services may be in an acute, general or specialized care hospital. Inpatient days subsequent to this admission notification period are subject to authorization rules; failure to notify as set forth herein may result in denial of payment.
• Care in a semi-private room of two or more beds is covered. Special treatment units licensed by the state, such as intensive or coronary care units are also covered, subject to scheduled copayments.
• Benefits for hospital care are limited to the hospital's most common charge for a semi-private (two-bed) room. If the member elects to have a private room, the member is responsible for any amount over the semi-private room rate, plus the plan copayment. If the PPG has authorized a private room as medically necessary, the member has no financial responsibility beyond the required copayment.
• All medically necessary inpatient services and supplies not specifically excluded for the condition necessitating confinement are covered, subject to the scheduled copayment.

Refer to the member's Evidence of Coverage (EOC), Certificate of Insurance (COI) or Schedule of Benefits for coverage information.

Services in a Skilled Nursing Facility, Acute, Long-Term, or Psychiatric Hospital

All admissions and services rendered in a skilled nursing facility (SNF), acute rehabilitation, long-term care, or psychiatric unit or hospital, even if located in the acute hospital's structure, are considered separate admissions. These services are distinct form the acute hospital services and are paid independent of the acute hospital admission once the member is discharged from the hospital and admitted to the designated unit.

Notification of SNF Admission and Discharge

To improve continuity and coordination of care for its members, Health Net requests that SNFs notify the member's PCP within 24 hours of admission to or discharge from a SNF.

When Health Net is the secondary payor and the member is admitted into a SNF or a long-term acute care (LTAC) facility, the facility needs to notify the plan upon admission or within 24 hours of exhaustion of the primary insurance. Health Net has a tracking system for members who are in facilities under a primary insurance, and notification is necessary to ensure that Medical Management has the ability to administer services for the member when Health Net becomes the primary payor.

To facilitate this process, Health Net has developed sample forms SNFs can use when notifying the member's PCP of an admission. If a SNF chooses to use its own notification forms, the following information must be included when notifying the member's PCP:

• Member name
• Identification (ID) number
• Date of birth (DOB)
• Admission date
• Admitting diagnosis
• Attending/admitting physician name
• Attending/admitting physician telephone and fax number
• Facility name
• Facility telephone and fax number
• Level of care

When notifying the member's PCP of a discharge from a SNF, the following information must be provided:

• Member name
• ID number
• DOB
• Admission and discharge dates
• Attending physician name
• Attending physician telephone and fax number
• Diagnosis
• Follow-up appointment date, if known
• Discharge destination
• Responsible party at discharge
• Level of assistance
• Discharge planning needs including equipment, service or other special training needs
• Medications, including dosage and frequency at discharge
• Facility name, telephone number and fax number
• Level of care

For additional information regarding SNF notification, refer to the Hospital Notification Unit (HMO or EPO and PPO) documents under the Utilization Management topic.