Out-of-Network Referrals

Provider Type

  • Participating Physician Groups (PPG)

A participating physician group (PPG) must refer members to participating providers except in emergencies or as otherwise required by law. PPGs are to use the following process when referring members to an out-of-network provider:

  • Determine whether an out-of-network referral is necessary and request prior authorization.
  • Have the PPG coordinator make an appointment for referral. When Health Net authorizes the referral request, the PPG coordinator arranges an appointment with the referred physician or specialist. When arrangements have been completed for the member's referral, the PPG coordinator makes a notation in the member's medical chart and completes the approrpriate form below: 
  • Enter all pertinent information and obtaining all required signatures. Verify that the referral services are covered by the member's plan, as, once Health Net authorizes a referral, the authorization cannot be withdrawn and payment is required for services rendered.
  • Inform member of copayments before services are performed. Some referral services require copayments. If the PPG fails to notify the member of a required copayment before the services are performed, no copayment can be charged.
  • Specify what services are being authorized. The PPG physician must specify at the time of the referral what services or treatments are being requested. Some PPGs find it useful to have the participating physician initially request an evaluation or consultation. After the results are returned, a treatment plan is reviewed and an extension of the authorization is requested.
  • Confirm referral services. Before referral services are performed, the referred physician must be aware that authorization is necessary for payment by the PPG. Health Net suggests that the PPG develop a standard letter to accompany the referral, explaining to the referred physician that only authorized services are reimbursed and that a member may not be charged for services.
  • Make a member aware of what services are being authorized and any limitations to the authorization. No reimbursement is provided for unauthorized follow-up visits.
  • Report member encounter information relating to referral services.
  • Provide assistance during the process to member as needed. The member cannot be expected to know all the steps in the referral process; the PPG must provide this information.

The PPG must inform referred physicians that they may not refer the member to, or otherwise obtain the services of, another physician or medical professional without authorization from the PPG.