Hospital Request for Authorization to Provide Post-Stabilization Services
- Participating Physician Groups (PPG)
Participating physician groups (PPGs) who receive a request for authorization for post-stabilization services from a non-participating hospital, of if the request comes from a participating hospital but the PPG is not delegated for inpatient services, must immediately notify the Health Net Hospital Notification Department upon receipt of any request from a hospital for authorization to provide post-stabilization services to Health Net members who have received emergency services. Do not issue an authorization or tracking number or confirmation of eligibility to the non-participating hospital.
A PPG in a dual-risk relationship with a hospital is responsible for complete utilization management (UM) for Health Net members to which the dual-risk relationship applies. Such UM includes confirming eligibility, issuing authorizations or tracking numbers, and arranging for member transfers or discharges, as appropriate. A PPG participating in a dual risk relationship should notify Health Net of any member admissions to non-participating hospitals.
Health Net calls the hospital back with the information necessary to initiate transfer of the member or provide an authorization for post-stabilization care. Pursuant to enactment of Assembly Bill 1203 (2008), which amended Health and Safety Code section 1262.8 (b)(3), after the emergency condition of the patient has been stabilized, a non-participating hospital is required to provide Health Net with the identity of the treating physician and surgeon's diagnosis and relevant medical information reasonably necessary for Health Net to coordinate with the PPG to assume management of the member's care by arranging for transfer of the member, or to provide authorization for medical necessity post-stabilization care. Under Health and Safety Code section 1317.1(j) a patient is "stabilized" or "stabilization" has occurred when, in the opinion of the treating provider, the patient's medical condition is such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from, or occur during, the release or transfer of the patient.
Refer to Emergency Services for more information specific to the member's health plan.