The hospital’s request for authorization is required once the member is stabilized following their initial emergency treatment and before the hospital admits them to the hospital for post-stabilization care. 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.

Hospitals are required to provide the treating physician and/or surgeon’s diagnosis and any other relevant information reasonably necessary for Health Net to decide whether to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer.

The requirement to request authorization for post‑stabilization care applies to both in‑network and out‑of‑network hospitals.

To request authorization for post‑stabilization care, the hospital must call the Health Net Hospital Notification Unit.

Do not contact the member’s PPG or any other Health Net contact point to request authorization for post‑stabilization care.

Post‑stabilization authorization requirements do not apply if the member has not yet been stabilized after emergency services and requires medically necessary continued stabilizing care.

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

A PPG in a dual-risk arrangement with a hospital is fully responsible for utilization management (UM) for members to whom 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. Pursuant to Health and Safety Code section 1262.8 (b)(3), 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.

Health Net may contest or deny claims for post-stabilization care following treatment in the emergency department or following an admission through a hospital’s emergency department when Health Net does not have a record of the hospital’s request for post-stabilization care via phone or a record that Health Net provided the hospital an authorization for such services.

If a patient’s Health Net identification (ID) card indicates enrollment through Medi-Cal, the member is under age 21, and services are related to a California Children’s Services (CCS)-eligible condition, the hospital should still request post-stabilization authorization from Health Net’s HNU using the procedure described above.

All requests for authorization, and responses to requests, must be documented. The documentation must include, but is not limited to:

Health Net is financially responsible for post-stabilization care services that are not pre-authorized, but are administered to maintain, improve, or resolve the member’s stabilized condition if the Plan:

If this situation applies, the Plan must give the treating provider the opportunity to consult with a Plan physician. The treating provider may continue with care of the member until a Plan physician is reached or one of the following criteria is met:

County Mental Health Plan information is available through the Department of Health Care Services. Health Net will coordinate with the County Mental Health Plan to transition the member once appropriate.

The Plan must approve or disapprove a request for post-stabilization care within 30 minutes. The post-stabilization care must be medically necessary for covered medical care. If a response to approve or disapprove the request is not provided within 30 minutes, the post-stabilization care request is considered authorized. This applies to any participating provider, subcontractor, downstream subcontractor, or nonparticipating provider.