Referrals to Specialists
Provider Type
- Physicians and Practitioners
- 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.
When referring a member for specialty care, the PCP must follow the guidelines outlined below as well as those dictated by the PPG:
- Choose a specialist from Health Net’s Medi‑Cal provider list or the PPG’s participating providers. The specialist must be contracted with the member’s assigned PPG; otherwise, the visit is considered out of network.
- For services with an out-of-network specialist, PCPs participating directly with Health Net must complete and fax the Inpatient California Medi-Cal Prior Authorization Form (PDF) or the Outpatient California Medi-Cal Authorization Form (PDF) to the specialist with the authorization number attached. PCPs participating through a PPG must follow the PPG's referral guidelines.
- For members assigned to Health Net Direct Network, 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.
- For members assigned to PPGs, PCPs must follow the guidelines outlined by the PPG.
- Select procedures performed by specialists may require prior authorization.
- When scheduling an appointment:
- The wait time for non-urgent specialty care must not exceed 15 business days and must be coordinated with the PCP based on the severity of the condition.
- Wait time for urgent specialty care appointments is 96 hours if prior authorization is required.
- Wait time for urgent specialty care appointments is 48 hours if prior authorization is not required.
- The specialist treats the member as indicated on the referral or 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 from Health Net or the PPG). 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 and follow PPG guidelines.
- Referrals are only valid between participating providers. Any referrals to nonparticipating providers require prior authorization from Health Net, its affiliated health plans, 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.