PPGs' Responsibilities for Authorization
Provider Type
- Participating Physician Groups (PPG)
Delegated participating physician groups (PPGs) perform the initial utilization review and authorization functions, while Health Net Medical Management staff manages services performed by non-delegated providers. Health Net is jointly responsible with the PPG for such functions when services are covered under shared-risk agreements.
Each PPG is responsible for:
- Contracting or arranging with licensed and certified providers for a full range of primary and specialty care services, as well as with key ancillary and subspecialty providers such as psychologists, family counselors, social workers, chiropractors, podiatrists, audiologists, and physical therapists
- Submitting copies of all referral provider contracts to Health Net for review and approval
- Monitoring the quality of care and the cost associated with services based on referrals to non-participating providers
- Obtaining encounter data from each referred physician
- Assuring timely payment to referral providers for covered services
PPGs must pay referred providers for covered services as soon as possible, and within 45 business days from receipt of the bill or as otherwise required under the PPGs' contracts with such providers in cases involving services to Medicare Advantage HMO members. If the PPG does not pay the referred provider within 45 business days of the date billed, Health Net has the option to pay the charges and deduct the amount from any payment due the PPG under the Health Net Provider Participation Agreement (PPA).
PPGs are responsible for using the following guidelines when authorizing services:
- Records of authorized services - The PPG must keep records of all authorized member services. This allows the PPG to monitor utilization of services by participating physicians and to compare the PPG records to the monthly reports provided by Health Net. Refer to the Medical Data Management Reporting discussion for additional information
- PPGs may not withdraw authorization after services are provided or when a member acts against medical advice - After a PPG authorizes a hospitalization, authorization cannot be withdrawn or payment denied because the member refuses to follow the directions of the attending physician. An example is a member self-discharging from the hospital against the attending physician's medical advice. Refer to the conditions for transfer between PPGs information under the Enrollment topic for additional information
- Collection of copayments for referrals - Refer to the plan chart in the Health Net Schedule of Benefits for each service provided to determine if a copayment is to be collected
PPGs may collect copayments or arrange collection of copayments for services based on referrals to non-participating providers, other than those mentioned above, with the providers of service. Health Net recommends, however, that the member pay copayments directly to the PPG for services based on referrals to non-participating providers so the PPG can monitor the fees charged and determines the correct copayments to be collected from the member. The PPG then reimburses the referred provider for their services.
Prior authorization for DSNP services not covered under Medicare but covered under Medi-Cal for members in Exclusively Aligned Enrollment (EAE) counties
Dual Special Needs Plan (DSNP) contractors are required to provide integrated organization determination for the DSNP members in Exclusively Aligned Enrollment (EAE) counties. For DSNP members in EAE counties, you must review both Medicare and Medi-Cal benefits to determine eligibility for the service requested. Do not deny prior authorization as “not a covered benefit” without checking both Medicare and Medi-Cal covered services (refer to the list of services below).
DSNP prior authorization timelines
PPGs should forward prior authorizations for the services that are not covered under Medicare but that are covered under Medi-Cal to Health Net within the following timelines:
- For standard requests, forward to Health Net within 1 business day upon receipt of the request.
- For expedited requests, forward to Health Net within 24 hours upon receipt of the request.
Fax authorizations to the Health Net Medi-Cal Prior Authorization Department fax number
Fax prior authorizations to the Medi-Cal fax number listed under Health Net Prior Authorization Department in the Provider Library’s Contacts section and include:
- The date and time that the service request was initially received.
- The clinical decision that was used to make the initial determination.
Services not covered under Medicare but covered under Medi-Cal
- Asthma remediation
- Community Based Adult Services
- Community Supports
- Community transition services/nursing facility transition services to a home
- Day habilitation programs
- Durable medical equipment (DME) that is covered by Medi-Cal
- Environmental accessibility adaptation (home modification)
- Housing deposit (up to $6,000)
- Housing tenancy and sustaining services
- Housing transition navigation
- Long-term care
- Medically tailored meals
- Nursing facility transition/diversion to assisted living facilities
- Personal care services and homemaker services
- Recuperative care
- Respite services
- Short-term post-hospitalization housing
- Sobering centers
Scenarios where PPGs would be responsible for sending out the Applicable Integrated Plan (AIP) Coverage Decision Letter
Refer to the below table to see the scenarios where PPGs are responsible for sending out the AIP Coverage Decision Letter. This will help PPGs determine when to forward the authorizations to the Plan and when to send the Applicable Integrated Plan Coverage Decision Letter for DSNP members in EAE counties.
Scenario | Delegated PPG | Health Plan |
|---|---|---|
Eligibility denial | Deny and send AIP coverage decision letter. | N/A |
Medical necessity denial | Deny and send AIP coverage decision letter. | N/A |
Scenarios where PPGs would be responsible for forwarding the request to the Health Plan
Scenario | Delegated PPG | Health Plan |
|---|---|---|
Benefit denial | Forward to Health Plan with the Medicare clinical decision. | Deny and send AIP coverage decision letter. |
Out of network | Forward to Health Plan with the Medicare clinical decision. | Deny and send AIP coverage decision letter. |
The Applicable Integrated Plan Coverage Decision Letter can be found in the Delegation Oversight Interactive Tool (DOIT) /MetricStream.