Guidelines for Transfer

Procedure for Member initiated Transfer

The monthly participating physician group (PPG) transfer policy allows the subscriber and each family member one PPG transfer each month for any reason; however, such transfer request is denied if the member is inpatient.

The member must request the provider change on or before the last day of the month in order for the change to be effective on the first of the following month. For example, a request received on July 31^st is effective August 1^st.

Procedure for PPG Initiated Transfer

The Health Net Member Services Department screens all transfer requests. The participating physician group (PPG) can only request transfer in case of just cause and must forward any requests for transfer to the Health Net Member Services Department for review. Only Health Net may approve or deny the transfer requests.

The Health Net Member Services Department may call the existing PPG to determine whether the member is hospitalized or pregnant. If the member is pregnant and gives birth within six months of the effective date with Health Net and is still enrolled in the new PPG at time of delivery, the delivery is covered under insured services.

The existing PPG assumes the expense for reproducing the member's medical records when the member transfers to another PPG.

Transfer of Newborns

A newborn, whether the subscriber's or subscriber's spouse's natural child, an adopted child or a child for whom the subscriber or spouse has become the legal guardian, is eligible for covered services for the first 30 days from birth regardless of whether the child is enrolled in the plan within those 30 days if the subscriber's or spouse's plan includes coverage for dependents. If the child is not added to the plan within 30 days from birth, the child is no longer covered and any services incurred after the 30th day are the financial responsibility of the child's parent or guardian.

When the biological mother of a newborn child is an enrolled member, the newborn must also be enrolled with the mother's participating physician group (PPG) at least until the first of the month following the date of birth. If the baby is ill at birth and confined to a hospital, the baby can be transferred on the first day of the month following discharge from the hospital. If the biological mother moves within the first 30 days of the baby's life and her PPG changes, the baby's PPG also changes, as long as the baby is not hospitalized at the time of the move.

When the biological mother of the newborn child is not enrolled, the child is automatically assigned to the subscriber's PPG until the first of the month following the date of birth. If the subscriber moves within the first 30 days of the baby's life or if the baby is ill at birth, the same conditions apply as noted above.

When the parents elect subsequently to transfer the child to a different PPG, they may do so, effective the first of the month following the newborn's date of birth, provided the newborn is a well baby. If a well baby becomes ill during the birth month and is hospitalized, transfer to another PPG is delayed until the first day of the month following hospital discharge.