Out-of-Area Emergency or Urgently Needed Care
- Physicians (does not apply to Cal MediConnect)
- Participating Physician Groups (PPG)
Health Net's definition for out-of-area services in HMO plans is care obtained outside a 30-mile radius from the member's primary care physician (PCP) office location or as defined in the Provider Participation Agreement (PPA).
To be covered, out-of-area care must be an emergency or urgently needed at a physician's office. Final determination of whether the services provided meet emergency criteria rests solely with Health Net.
Direct Members to the Nearest Participating Physician Group or Primary Care Physician
If an injury or illness requires emergency services, members are instructed to call 911 or go to the nearest hospital or urgent care center. When members receive emergency services, they must contact their PCPs or participating physician groups (PPGs) as soon as possible to notify them of the emergency services received. Members traveling out-of-area, but within California, who call their PPG or PCP for assistance with an emergency or urgent care need should be directed to the nearest PPG or PCP when possible. Instruct out-of-area providers to contact Health Net directly for authorization.
The PPA states that a participating provider must provide emergency or urgently needed care to Health Net members who are temporarily outside their service area. Providers should verify a member's eligibility with Provider Services or the member's selected PCP specified on the member's Health Net identification card.
The Health Net provider directory lists all PPGs and PCPs and is available online and updated daily. Participating providers may also log in to the Health Net provider portal and locate a provider or contact their Health Net provider relations or contracting specialist (formally known as the provider network administrator) or regional network manager.