Participating physician groups (PPGs) must immediately notify the Health Net Hospital Notification Department when:

PPGs do not provide an authorization, tracking number or eligibility confirmation to a non-participating hospital.

A PPG in a dual-risk arrangement with a hospital is fully responsible for utilization management (UM) for members to which the dual-risk relationship applies. Such UM includes eligibility verification, issuing authorizations or tracking numbers, and coordinating transfers or discharges. The PPG must immediately notify Health Net of any member admissions to non-participating hospitals to support Health Net in meeting regulatory requirements, which mandates a response within 30 minutes of a request for post stabilization services.

Health Net contacts the hospital with the information needed to either initiate member’s transfer or authorize post-stabilization care. In California, under Assembly Bill 1203 (2008), which amended Health and Safety Code section 1262.8 (b)(3), non-participating hospitals must, once the member’s emergency condition is stabilized, provide Health Net with the treating physician’s identity and diagnosis and relevant medical information. This allows Health Net to coordinate with the PPG to manage the member’s care through either transfer or authorization of medical necessary post stabilization services.

Under Health and Safety Code section 1317.1(j) a patient is "stabilized" or "stabilization" has occurred when, in the treating provider’s judgment, the patient's condition is such that, within reasonable medical probability, no significant deterioration is likely or occur during or as a result of the patient’s transfer or release. For hospitals outside of California, post-stabilization services are not subject to prior authorization, as they are considered part of emergency services under the No Surprises Act.

Refer to Emergency Services for more information specific to the member's health plan.