Sexually Transmitted Infections (STIs)
- Participating Physician Groups (PPG)
- Los Angeles
- San Diego
- San Joaquin
Diagnosis and treatment of sexually transmitted infections (STIs) are available to Health Net Medi-Cal members without prior authorization under Health Net's contract with the Department of Health Care Services (DHCS). Members may choose any qualified provider, in- or out-of-network, including local health departments (LHDs) and family planning clinics, for care of an STI episode without prior authorization. STI services include education, prevention, screening, counseling, diagnosis, and treatment.
Out-of-network services provided by LHDs and family planning providers are limited to the following:
- One visit for STIs that are amenable to immediate diagnosis and treatment including: bacterial vaginosis, trichomoniasis, candidiasis, herpes simplex, human papillomavirus, gonorrhea, non-gonococcal urethritis, and Chlamydia
- One initial visit for primary or secondary syphilis and up to five additional visits for clinical and serological follow-up and treatment
- A maximum of three visits for diagnosis and treatment of chancroid, lymphogranuloma venereum, granuloma inguinale, and pelvic inflammatory disease (PID)
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:
- Member demographics (name, age, address, home telephone, date of birth, gender, ethnicity, and marital status)
- Locating information (employer, work address and telephone number)
- Disease information (diagnosed date of onset, symptoms, laboratory results, and prescribed medications)
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.
Claims for reimbursement are processed within 30 days of receipt, unless the PPA requires that claims be processed sooner. Providers are notified in writing of any contested claim in suspense longer than 30 days.
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.