Referrals
Provider Type
- Physicians
- Hospitals
- Participating Physician Groups (PPG)
Referrals to Health Net
The following process applies to cases that need to be referred to the Health Net Medical Management Department:
- The referral is made to the Health Net care management intake coordinator in the Medical Management. Most cases are identified through the inpatient concurrent review process, but referrals are accepted from any source. Indicators that a member may be appropriate for care management may be based on diagnosis, potential treatment, frequent hospitalizations, extended hospitalizations, location of care, and patterns of care.
- The case is assigned to a Health Net care manager.
- The Health Net care manager assesses the member's medical care needs by talking with the member, family (if the member is a minor or is incapable of self-representation) and the referral source.
- The Health Net care manager requests all pertinent medical records from the primary care physician (PCP), involved hospitals, specialists, therapists, and other treatment or referral sources.
- The Health Net care manager notifies the referral source, member or guardian, PCP, and participating physician group (PPG), if applicable, of the member's eligibility for the Health Net care management program. If the member is not eligible for the program, the Health Net care manager may offer suggestions or alternatives for the member to pursue.
- The Health Net care manager develops a care management plan (CMP) in collaboration with the health care team, family and member that is reviewed with the Health Net Medi-Cal medical director. If the CMP is approved, the Health Net care manager contacts the PCP and other involved health care providers to discuss implementation.
- The CMP is followed and referrals and prior authorizations are sought within the system.
- The PCP makes the referrals and treatment is initiated.
- The Health Net care manager reviews the CMP and the member's progress at least once every 30 days, allowing for re-evaluation in the event of a change in medical condition. Short-term referrals, expected to last three months or less, are reviewed more frequently. Any changes in the CMP are submitted to the PCP for approval.
Referrals to State or County Care Management
When a member is identified as eligible for a county or state-supported health care program, a Health Net care manager or review nurse assists the PCP, on request, in ensuring timely referral. The PCP makes the referral and coordinates primary medical care for members who are eligible for any of the carve-out programs. Health Net's care managers also serve as liaisons between the PCP and the county carve-out services coordinator to ensure exchange of information and provision of primary health care for individual members.
Los Angeles County - Referrals to Affiliated Health Plans
PPGs to which Health Net has delegated responsibility for care management services must refer members identified as potential care management recipients to the affiliated health plan's utilization management (UM) or health care services department.
Identification of Potential Care Management Recipients
Members are referred by the primary care physician (PCP) or specialist for individual medical care management services for high-risk medical conditions. The following list of medical conditions represents the type of conditions that must be referred for comprehensive care management:
- Multiple trauma with acute extended length of stay (ELOS) greater than 10 days
- Severe neurological diseases that are chronic degenerative (for example, amyotrophic lateral sclerosis (ALS))
- Complex multi-diagnostic cases
In addition, Medi-Cal managed care members with the following medical conditions must be referred to care management for referral to the applicable state or county program:
- All transplant cases for members under age 21
- Multiple congenital birth defects
- Pre-term births, including those eligible for high-risk follow up from California Children's Services (CCS)
- Members with AIDS
- Children with special health care needs eligible for Regional Center care
- Children with CCS eligible conditions
- Children over age three with speech/language delay
Additional information regarding eligibility requirements for public health programs, such as Regional Centers and CCS, is provided in the Public Health topic.