- Participating Physician Groups (PPG)
A physician may decide that it is necessary for the member to receive treatment from another physician or specialist and should refer the member to a PPO in-network physician when possible. No prior authorization is required. If the member is referred to an out-of-network provider, the member's benefits are reduced and a higher out-of-pocket cost is incurred. To determine if the specialist is a PPO in-network physician, contact the Health Net Provider Services Department or consult the Health Net website.
Identifying PPO Participating Providers
The Health Net provider directory lists the network physicians, hospitals and ancillary providers that are participating in the PPO health plans. When referring members to other providers, use the directory or consult the Health Net website.
Referring Members to Out-of-Network Providers
A PPO participating provider is responsible for referring members to other Health Net participating providers unless, in the provider's professional judgment, the member's needs require a referral to an out-of-network provider. In this case, the member must be notified that the proposed referred provider is not a Health Net participating provider.
The member is responsible for the scheduled copayment and deductible, plus any amounts that exceed Health Net's maximum out-of-network reimbursement. Additionally, the member may be required to pay the bill in full to the provider and request reimbursement from Health Net.
When a referral is made to a participating provider, the in-network benefits are applicable, resulting in a lower out-of-pocket expense for the member.