21-278 Nonpar Hospital ER Admit Post-Stabilization
Date: 04/09/21
This information applies to Hospitals.
ATTENTION!
Nonparticipating hospitals must follow the processes outlined in this letter when obtaining prior authorization for post-stabilization care pursuant to AB1203.
Pursuant to California Health and Safety Code sections 1262.8 and 1371.4 (AB 1203), a nonparticipating hospital is required to obtain authorization for post-stabilization care from a health care service plan, such as Health Net, once a patient who is an enrollee of the health care service plan is stabilized after presenting with an emergency medical condition. Authorization is required for both outpatient and inpatient post-stabilization care.
This request for authorization requirement applies only to a hospital whose patient is an enrollee of a Health Net HMO (both commercial and Medi-Cal), Point of Service (POS) or HSP contract. The request for authorization is required once the patient is stabilized following emergency treatment and the hospital seeks authorization for post-stabilization care, and the services of the hospital are not subject to a written Provider Participation Agreement (PPA) between the hospital and Health Net for the applicable member’s plan.
A request for authorization must be made via telephone to Health Net’s Hospital Notification Unit (HNU) at 800-995-7890, option 1. Under Health and Safety Code section 1262.8(b)(3), a hospital is required to provide Health Net with the treating physician and surgeon’s diagnosis and any other relevant information reasonably necessary for Health Net to make a decision to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer. A hospital’s contact with any other Health Net telephone or fax number, or the patient’s participating physician group (PPG), to request authorization to provide post-stabilization care does not satisfy the requirements of the above laws. Do not contact the patient’s PPG or any other Health Net telephone or fax number to request Health Net’s authorization for post-stabilization care.
See below for an addendum explaining a temporary suspension of certain prior authorization requirements due to COVID-19.
1 A patient is “stabilized” or “stabilization” has occurred when, in the opinion of the treating provider, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, the release or transfer of the patient.
Health Net may contest or deny claims for post-stabilization care following treatment in the emergency department or following an admission through a hospital’s emergency department where Health Net does not have a record of the hospital’s required telephone call to 800-995-7890, option 1 or a record that Health Net provided the hospital with an express authorization for such services.
If a patient’s Health Net identification (ID) card indicates enrollment through Medi-Cal, the member is under age 21, and services are related to a California Children’s Services (CCS)-eligible condition, the hospital should call Health Net’s HNU at 800-995-7890, option 1 and then immediately seek authorization for treatment from CCS by faxing a Service Authorization Request (SAR) with medical records to the local county CCS office. If your facility is not CCS-approved, the member must transfer to a CCS-approved facility. Health Net cooperates with hospitals that seek CCS authorization for treatment but does not provide authorization for services for which CCS is financially responsible.
Below is Health Net’s 24-hour HNU contact number to be used by nonparticipating hospitals to notify Health Net once a patient who is enrolled in a Health Net HMO, POS, HSP, or Medi-Cal plan is stabilized, and to initiate a request for authorization of additional services.
Health Net Hospital Notification Unit Contact Information
Please use the telephone number below to notify Health Net of stabilized patients and to request authorization for additional services. Failure to contact Health Net may result in Health Net’s contesting or denying claims for reimbursement. A hospital’s contact with any other Health Net telephone or fax number or the enrollee’s participating physician group (PPG) to request authorization to provide post-stabilization care does not satisfy the requirements of applicable laws. Do not contact the patient’s PPG or other Health Net telephone or fax number to request
Health Net’s authorization for post-stabilization care.
Hospital Notification Unit Telephone Number | |
|---|---|
Health plan | Telephone number |
All Health Net lines of business* | 800-995-7890, option 1 |
*If a patient’s Health Net identification (ID) card indicates enrollment through Medi-Cal, the member is under age 21, and services are related to a California Children’s Services (CCS)-eligible condition, the hospital should call the Health Net HNU contact number and then immediately seek authorization from CCS by faxing a Service Authorization Request (SAR) with medical records to the local county CCS office. If your facility is not CCS-approved, the member must transfer to a CCS-approved facility. Health Net cooperates with hospitals that seek CCS authorization for treatment, but does not provide authorization for services for which CCS is financially responsible.
Addendum:
Due to the COVID-19 state of emergency, the requirement for prior authorization for post-stabilization care and the Health Net Hospital Notification Unit (HNU) 800 number are temporarily suspended. While the prior authorization requirement is presumed to be met, the requirement to timely notify Health Net of admission remains.
During the suspension, Health Net non-participating or non-contracted hospitals, skilled nursing facilities, long-term care facilities, and long-term acute care hospitals should submit inpatient admission notifications by fax to 800-676-7969.
To get the status of an urgent inpatient authorization call the Provider Services Center at the applicable number below. The Provider Services Center will escalate any inquiries directly to the HNU, as needed.
Provider Services Center by Line of business | Telephone number |
|---|---|
Employer Group HMO, POS, HSP, PPO and EPO | 800-641-7761 |
Enhanced Care PPO (IFP and SBG) | 844-463-8188 |
Individual Family Plan (includes CommunityCare HMO, PureCare HSP, PureCare EPO and PPO IFP) | 888-926-2164 |
Medi-Cal | 800-675-6110 |
Medicare Advantage: Green, Health Heart I, Ruby, Violet plans | 800-929-9224 |
Medicare Advantage: Amber, Amber I, Amber II, Healthy Heart II plans | 800-646-5614 |
First Health Provider Relations | 800-937-6824 |
You will be notified when the HNU 800 number and the requirement for prior authorization for post-stabilization care is again active. Until then, please fax your inpatient notifications to 800-676-7969 and call the numbers above for status.