PPG Responsibilities for Referral Tracking

Participating physician groups (PPGs) delegated for utilization management (UM) functions are required to develop and implement policies and procedures for tracking whether Health Net members actually obtained services authorized pursuant to a referral.

In accordance with the California Department of Health Care Services (DHCS) requirements, Health Net requires PPGs to track member compliance with referrals within their network. PPGs may consider generating monthly reports on outstanding or expired referrals. These reports can be used at both the PPG and primary care physician (PCP) level to monitor completion and follow-up on referrals for specialty services.

Health Net's medical program managers (MPMs) monitor delegated PPGs for compliance with this responsibility as part of the PPG's annual UM audit and continuous oversight activities.