- Participating Physician Groups (PPG)
Care coordination refers to the system of directing and monitoring a member's care among multiple health care providers, encounters and procedures so that the member receives timely, medically necessary health services without interruption.
The system comprises several procedural components that are required based on the extent of the severity of the member's health condition. Basic procedures required of primary care physicians (PCPs) to maintain care coordination are:
- Documentation of member encounters, missed appointments, extensions of appointment waiting time (noted that a longer waiting time for appointment will not have a detrimental impact on the health of the member), and referrals in members' medical record
- Referral of members needing specialty health services
- Forwarding summaries of pertinent medical findings to specialists
- Documentation of services provided by a specialist in the member's primary care medical record
- Monitoring members who have ongoing medical conditions
- Notifying Health Net of member referrals to specialists, care management or public health programs
Additional procedures are required of PCPs when members' health conditions require urgent, emergency or inpatient health services, including:
- Documentation in members' medical records of emergency and urgent medical care and follow-up
- Coordinated hospital discharge planning
- Post-discharge care
Health Net suggests that each provider develop protocols to maintain care coordination. A log system for tracking prior authorizations, referrals to specialists, follow-up of missed appointments, and acknowledgment and verification of such things as lab and X-ray findings is recommended. The system can be manual or computerized.
The following applies to participating physician groups (PPGs) and hospitals only.
Report all admissions with an expected length of stay (ELOS) greater than 10 days and all cases identified meeting provider stop loss criteria. Fax information to the Health Net Hospital Notification Unit.
The provider must develop office procedures to remain informed about changes in the member's status (for example, member changed primary care physician (PCP), has been hospitalized or has died) with notation in the medical record.
The provider may obtain this information from member enrollment data. Further, the provider should receive information regarding hospital admissions within 24 hours or by the next business day from the facility, the member or Health Net (or affiliated health plan in Los Angeles County).
Specialists are required to submit written reports to the referring physician. These written reports must include the specialist's findings, recommended treatment, results of any studies, tests, procedures, and recommendations for continued and or follow-up care. The primary care physician (PCP) must receive the report within two weeks of the member's visit with the specialist. Emergency or urgent care reports or findings must be called to the PCP within 24 hours or by the next business day.
The PCP is required to review the specialist's findings to determine whether follow-up care is medically necessary. The PCP is responsible for directing all member care through the referral process.
Services Received in an Alternate Care Setting
The PCP should receive a report with findings, recommended treatment and results of treatment for services performed outside the PCP's office.
The provider may also receive emergency department reports, hospital discharge summaries and other information.
Home health care agencies submit treatment plans to the PCP after an authorized evaluation visit and every 30 days afterward for review of home health care and authorization.
The PCP should also receive reports regarding diagnostic or imaging services with abnormal findings or evaluations and subsequent action.
The following applies to particpating physician groups (PPGs) and physicians only.
Appointments may be missed due to member cancellation or no show. The Department of Health Care Services (DHCS) requires the provider to attempt to contact the member a minimum of three times when they miss an appointment. Attempts to contact must include:
- First attempt - phone call to member. (A written letter must be sent if the member does not have a phone.)
- Second attempt - if member does not respond to the first attempt, a second phone call must be made to the member. (A written letter must be sent if the member does not have a phone.)
- Third attempt - if member does not respond to the second attempt, a written letter must be sent.
For members under age 21, failure to respond to the primary care physicians (PCPs) follow-up attempt must be reported to Health Net's public programs administrators.
Documentation must be noted in the member's medical record regarding any missed or canceled appointments, reschedule dates and attempts to contact. Health Net recommends the use of a rubber stamp to document this information in the chart.
Missed Procedure or Laboratory Test
Appointments for procedures or tests may be missed or canceled. The provider must contact the member by phone or letter to reschedule. Documentation must be noted in the medical record regarding any missed or canceled procedures or tests, reschedule dates and any attempts to contact the member.
Providers must report to Health Net all Medi-Cal members who have been referred to public health programs, excluding those referred for sensitive services (such as HIV testing and counseling, family planning, and alcohol and drug abuse treatment). Notification to Health Net Health Care Services may be made via mail or fax and must include the following information:
- Member name
- Member identification number
- Provider name
- Type of referral
- Date of referral
- For California Children's Services (CCS), include diagnosis
The following applies to particpating physician groups (PPGs) and physicians only.
A specialist may serve as a primary care physician (PCP) for Medi-Cal members who are Seniors and Persons with Disabilities (SPDs). The specialist must agree to serve as a PCP and be qualified to treat the required range of conditions of the SPD member.
SPD members may request a specialist as a PCP, as follows:
- SPD members may contact the Health Net Medi-Cal Member Services Department, Community Health Plan of Imperial Valley Member Services Department or the CalViva Health Medi-Cal Member Services Department for assistance with PCP selection.
- If the SPD member requests a specialist as a PCP, the Medi-Cal Member Services Department representative obtains the necessary information from the SPD member, including the specialist's name and participating physician group (PPG) affiliation (if applicable).
- The Medi-Cal Member Services Department representative forwards the SPD member's request for a specialist as a PCP to Health Net, Molina Healthcare, or the delegated PPG's designated intake department.
- The Health Net, Molina Healthcare or delegated PPG's designated intake representative contacts the specialist and explains the requirements for serving as a PCP (refer to PCP Responsibilities section below), including the facility site review (FSR) requirements. The representative may also contact the member to discuss the process and reassure the member that they chose specialist can continue to see the member as a specialist even if the provider does not choose to become a PCP. PPGs are encouraged to work with members to help them establish a medical home with their chosen PCP.
- If the specialist agrees to serve as a PCP and is qualified to treat the required range of conditions of an SPD member, the Health Net, Molina Healthcare or delegated PPG's designated representative initiates the process to conduct a full-scope FSR. A member cannot be assigned to a specialist who is serving as a PCP until the specialist's office has passed the FSR.
- After the specialist passes the FSR, the applicable Health Net, Molina Healthcare, or delegated PPG's designated representative submits the documentation to change the provider's status in Health Net's data management system from a specialist to a PCP.
Once the contracting specialist agrees to serve as, and is designated by Health Net to serve as a PCP, they are no longer designated as a contracting specialist in Health Net's network.