Referrals to Specialists
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
A referral is required for cases that are difficult to manage or when care is beyond the primary care physician's (PCP's) scope of practice. Refer to the Referral for Specialty Consultation discussion for a summary of some of the services that may be referred to a specialist.
Health Net delegates the referral process to full and shared-risk participating physician groups (PPGs). Referrals to participating and non-participating specialists for members assigned to a capitated PPG are subject to any additional rules imposed by the PPG. PPGs may not impose referral or authorization requirements that conflict with the member's right to self-refer.
Los Angeles County
When referring a member for specialty care, the PCP must follow the guidelines outlined below, as well as those dictated by the PPG:
- Select a specialist from a list of participating providers in the PPG
- Follow the PPG's referral guidelines
- When scheduling an appointment, the wait time for specialty care must not exceed 15 business days and must be coordinated with the PCP based on the severity of the member's condition
- The specialist treats the member as indicated on the referral and notifies the PCP of the findings
- The specialist may order diagnostic tests, X-ray and laboratory services, and durable medical equipment (DME). The specialist must follow the PPG's referral guidelines and use the participating provider network when referring for lab, X-ray, DME, and other ancillary services
- If the member requires treatment beyond the services requested by the PCP, the specialist must contact the PCP for an additional referral, as required by PPG guidelines
- Referrals are only valid between participating providers. Any referrals to non-participating providers require prior authorization from the PPG or Health Net or its affiliated health plans, depending on the PCP's contract affiliation
- If an out-of-network referral is necessary, due to medical necessity or patient need, even if a participating provider is closer, the referral benefit is at the member's in-network cost of share.
All Other Counties
When referring a member for specialty care, the PCP must follow the guidelines outlined below:
- Select a specialist from the list of participating providers in Health Net's Medi-Cal provider listing or from a list of participating providers in the PPG
- For services with an out-of-network specialist, PCPs participating directly with Health Net must complete and fax the Inpatient Califonria Medi-Cal Prior Authorization Form (PDF) or the Outpatient California Medi-Cal Authoirization Form (PDF) to the specialist with the authorization number attached. PCPs participating through a PPG must follow the PPG's referral guidelines
- If an out-of-network referral is necessary, due to medical necessity or patient need, even if a participating provider is closer, the referral benefit is at the member's in-network cost of share.
- For specialty visits with participating specialists, there is no need to complete a prior authorization form or notify Health Net; however, many specialists prefer an authorization number prior to performing services. As a courtesy to the specialist, Health Net provides the PCP with an authorization number upon request from the PCP or specialist
- When scheduling an appointment, the wait time for specialty care must not exceed 15 business days and must be coordinated with the PCP based on the severity of the condition
- The specialist treats the member as indicated on the Prior Authorization Request form and notifies the PCP of the findings
- The specialist may order diagnostic tests, X-ray and laboratory services, and durable medical equipment (DME) (some services may require prior authorization)
- If the member requires treatment beyond the services requested by the PCP, the specialist must contact the PCP for an additional referral
- Referrals are only valid between participating providers. Any referrals to nonparticipating providers require prior authorization from Health Net or the PPG, with the exception of those services for which members may self-refer without prior authorization
Referrals between specialists are not covered. When a specialist determines that referral to another specialist is needed, the PCP must be notified and requested to make the referral.