Authorization for Admission to Hospital or SNF
- Participating Physician Groups (PPG)
When a participating physician determines that inpatient or outpatient hospital services are necessary for a member, the participating physician group (PPG) coordinator makes the necessary arrangements following established procedures for review and approval.
Authorization Requirements for Maternity Inpatient Stay
As required by law, Health Net provides mother and newborn coverage for minimum hospital stays of at least 48 hours following a vaginal delivery or at least 96 hours following a cesarean section without authorization. Coverage for inpatient hospital care may be for less than 48 or 96 hours, respectively, only if both the treating physician and the member agree to an earlier discharge. Refer to the Maternity discussion under the Benefits topic for additional information.
If a member is discharged earlier than the 48 or 96 hours allowed by law, the treating physician has discretion to prescribe a post-discharge follow-up visit at home, in a facility, or in the physician's office within 48 hours after discharge. This covered visit must be provided by a licensed health care provider whose scope of practice includes postpartum and newborn care.
Length of stays longer than noted above require authorization and notification in order to conduct utilization management activities.
PPG Must Report SNF - Confined Members to Health Net
PPGs are required to identify and report to the Hospital Notification Unit all members who are scheduled for admission to a skilled nursing facility (SNF) or are confined to an SNF.
For additional information regarding SNF notification, refer to Notification of Hospital Admissions.