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. Notification to Health Net must be done immediately for the Plan to abide by the regulatory requirements of having a response within 30 minutes of the initial request.

Health Net calls the hospital back with the information necessary to initiate transfer of the member or provide an authorization for post-stabilization care. For hospitals in California, 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. For hospitals outside of California, post-stabilization services are not subject to authorization as it is included in ER services pursuant to the No Surprises Act.

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