Out-of-network services provided by LHDs and family planning providers are limited to the following:

Additional visits require prior authorization and may require that the member be referred back to his or her primary care physician (PCP) for any additional medically necessary follow-up or treatment.

For community providers other than LHD and family planning providers, out-of-network services are limited to one office visit per disease episode (follow-up care must be obtained by an in-network provider).

Member education on sexually transmitted infections (STIs) includes disease-specific material, the right to out-of-network treatment, health assessment for risk factors, and the method for obtaining preventive services. Members are advised of these services in the Evidence of Coverage (EOC).

The Health Net Health Education Department sends STI health education information to providers on request.

Health Net requests that nonparticipating providers contact the Health Net Medi-Cal Member Services Department to verify eligibility and benefits and to obtain billing instructions for Medi-Cal members. The nonparticipating provider is given the name of the member's primary care physician (PCP) to arrange for follow-up services. Nonparticipating providers may also use either an EDS Point of Service (POS) device or the Automated Eligibility Verification System (AEVS) by telephone to confirm eligibility. If the nonparticipating provider contacts the PCP directly, the PCP is responsible for coordinating the member's care with the non-participating provider.

If the nonparticipating provider requests care management services, the request is forwarded to the Health Net Medi-Cal Health Services Department. The Health Net Medi-Cal Health Services Department arranges for any necessary follow-up care and coordinates the care with the member's PCP.

Primary care physicians (PCPs) are responsible for primary treatment of sexually transmitted infections (STIs). The PCP may perform the service or may refer members to local health department (LHD) clinics, participating specialists, or on request of the member, out-of-network providers.

PCPs are responsible for reporting incidences of STIs to the LHD within specific time frames. Refer to the Communicable Diseases Reporting discussion under the Compliance and Regulations topic for a list of reportable STIs, reporting requirements and the Confidentiality Morbidity Report form (PDF).

When reporting to the LHD, the following information must be included:

Plan PCPs shall screen for chlamydia in all sexually active women 24 years or younger and women 25 years or older who are at increased risk for infection, in accordance with the U.S. Preventive Services Task Force (USPSTF) recommendations. Follow up for positive results must be documented in the medical record.

If the member refuses to have the chlamydia screening performed, unsuccessful attempts and refusals to screen must be documented in the member's medical record by the PCP.

PCPs should document any preventive care and health education counseling provided at the time of a routine exam for all members with high-risk behaviors for STIs.

Access to STI services by minors, including confidentiality and monitoring of STI services, is a covered benefit. Refer to the Access to Sensitive Services discussion under the Benefits topic for additional information.

Participating providers must bill Health Net, or the capitated participating physician group (PPG), in accordance with their Provider Participation Agreement (PPA) .

Individually participating providers who provide sexually transmitted infection (STI) services are reimbursed at the allowable Medi-Cal fee-for-service (FFS) rate determined by the Department of Health Care Services (DHCS), if a specific rate has not been included in the PPA .

Denials of STI services (for example, member ineligibility under the Medi-Cal program) are sent to the provider of service to protect the member's privacy.

Plan Medi-Cal providers may submit appeals to the Provider Disputes Department for any unresolved claims issue. The procedure is outlined for providers in the Plan’s Medi-Cal Provider Manual.

Members may submit appeals to the Plan’s Medi-Cal Member Appeals and Grievance Department for any unresolved claims issue. The procedure is outlined for Members in the Evidence of Coverage document. Any questions or issues should be referred to the Plan’s Medi-Cal Customer Contact Center.