PPGs' Responsibilities for Authorization
- Participating Physician Groups (PPG)
Delegated participating physician groups (PPGs) perform the initial utilization review and authorization functions, while Health Net Medical Management staff manages services performed by non-delegated providers. Health Net is jointly responsible with the PPG for such functions when services are covered under shared-risk agreements.
Each PPG is responsible for:
- Contracting or arranging with licensed and certified providers for a full range of primary and specialty care services, as well as with key ancillary and subspecialty providers such as psychologists, family counselors, social workers, chiropractors, podiatrists, audiologists, and physical therapists
- Submitting copies of all referral provider contracts to Health Net for review and approval
- Monitoring the quality of care and the cost associated with services based on referrals to non-participating providers
- Obtaining encounter data from each referred physician
- Assuring timely payment to referral providers for covered services
PPGs must pay referred providers for covered services as soon as possible, and within 45 business days from receipt of the bill or as otherwise required under the PPGs' contracts with such providers in cases involving services to Medicare Advantage HMO members. If the PPG does not pay the referred provider within 45 business days of the date billed, Health Net has the option to pay the charges and deduct the amount from any payment due the PPG under the Health Net Provider Participation Agreement (PPA).
PPGs are responsible for using the following guidelines when authorizing services:
- Records of authorized services - The PPG must keep records of all authorized member services. This allows the PPG to monitor utilization of services by participating physicians and to compare the PPG records to the monthly reports provided by Health Net. Refer to the Medical Data Management Reporting discussion for additional information
- PPGs may not withdraw authorization after services are provided or when a member acts against medical advice - After a PPG authorizes a hospitalization, authorization cannot be withdrawn or payment denied because the member refuses to follow the directions of the attending physician. An example is a member self-discharging from the hospital against the attending physician's medical advice. Refer to the conditions for transfer between PPGs information under the Enrollment topic for additional information
- Collection of copayments for referrals - Refer to the plan chart in the Health Net Schedule of Benefits for each service provided to determine if a copayment is to be collected
PPGs may collect copayments or arrange collection of copayments for services based on referrals to non-participating providers, other than those mentioned above, with the providers of service. Health Net recommends, however, that the member pay copayments directly to the PPG for services based on referrals to non-participating providers so the PPG can monitor the fees charged and determines the correct copayments to be collected from the member. The PPG then reimburses the referred provider for their services.