PPG Responsibility

Participating physician groups (PPGs) must address the following items to help ensure compliance with federal regulations:

1. PPGs must allow female members to self-refer to gynecologist providers within the member's PPG.
2. PPGs may not collect copayments from Health Net members for annual mammograms.

• If the PPG is not affiliated with a mammography center, a list of certified centers is available from Cancer Information Services or the Food and Drug Administration's (FDA's) website at www.fds.gov.
• Capitated PPGs are liable for fee-for-service (FFS) claims if the member obtains services from an out-of-network mammography center.

The Centers for Medicare & Medicaid Services (CMS) and Health Net review each participating physician group's (PPG's) list of mammography centers to determine sufficient member access within the PPG. If members obtain these services from unaffiliated or noncontracting facilities due to insufficient member access, Health Net has the authority to bill the PPG for the charges.