On receipt of admission notification, Health Net creates a tracking number and provides to the reporting party. The tracking number is not an authorization that services are covered under a member's benefit plan. Any services authorized by Health Net at the time of notification or thereafter are noted in the Health Net notification system. The tracking number is also transferred electronically to the Health Net claims processing system. To report a Health Net member inpatient admission, contact the Health Net Hospital Notification Unit.

Notification of after-hours admissions may be made by phone (the information is recorded by voicemail), fax, or web. On the next business day, a Health Net representative verifies eligibility, obtains information regarding the admission and, if applicable, provides a tracking number for the case.

When reporting inpatient admissions, providers must have the following information:

• Member name.
• Subscriber identification (ID) number.
• Attending and admitting physicians' first name, last name and contact information.
• Admission date and time of admission.
• Admission type (such as emergency room, elective or urgent).
• Facility name and contact information.
• Level of care.
• Admitting diagnosis code.
• CPT procedure code, if available.
• Facility medical record number.
• Participating physician group (PPG) authorization number.
• For obstetrical (OB) delivery admissions, include newborn sex, weight, apgar score, time of birth, and medical record number.
• Discharge date, if applicable.
• Other insurance information, if applicable.

Timely notification of Health Net member inpatient admissions assists with timely payment of claims, reduces retroactive admission reviews and enables Health Net to concurrently monitor member progress. Health Net requires the following facilities to notify BOTH the Health Net Hospital Notification Unit AND the PPG (if applicable) or provider of a member's inpatient admission within 24 hours (or one business day when an admission occurs on a weekend or holiday) for the following services:

Requests for Authorization for Post-Stabilization Care at Non-Participating and Participating Hospitals

Health Net is responsible for the coverage and payment of emergency services and post-stabilization care services to the provider that furnishes the services. This can be a participating provider, subcontractor, downstream subcontractor, or nonparticipating provider.

Requests for post-stabilization authorization

The requirement to request authorization applies to both in-network and out-of-network hospitals when treating members.

The hospital’s request for authorization is required once the Health Net member is stabilized following their initial emergency treatment and before the hospital admits them to the hospital for inpatient post-stabilization care. 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.

Hospitals are required to provide the treating physician and/or surgeon’s diagnosis and any other relevant information reasonably necessary for Health Net to decide whether to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer.

How to request post-stabilization authorization

To request authorization for post-stabilization care, the hospital must call the Hospital Notification Unit.

A hospital’s notification to Health Net of emergency room treatment or admission does not satisfy the requirement to request post-stabilization care. Post-stabilization requirements do not apply if the member has not been stabilized after emergency services and requires medically necessary continued stabilizing care.

A hospital’s contact with any other phone or fax number or website, or the patient’s participating physician group (PPG), to request authorization to provide post-stabilization care does not satisfy the requirements of the above required procedures. Do not contact the member’s PPG or any other Health Net phone, fax number or website to request Health Net’s authorization for post-stabilization care.

Behavioral health emergencies

Marketplace/IFP (Ambetter HMO and PPO) and Employer Group HMO/POS and PPO members: Health Net covers mental health and substance use disorder treatment that includes behavioral health crisis services provided to a member by a 988 crisis call center, mobile crisis team or other behavioral health crisis services providers, regardless of whether that provider or facility is in network or out of network. Hospitals must use the above number to request authorization for members’ post-stabilization care once they are deemed stable but require facility-based care.

Providers can access the Transitions of Care Management (TRC) Worksheet to:

Response time to requests

Health Net must approve or disapprove a request for post-stabilization care within 30 minutes. The post-stabilization care must be medically necessary for covered medical care. If the response to approve or disapprove the request is not given within 30 minutes, the post-stabilization care request is considered authorized.

Failure to request post-stabilization authorization

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 when Health Net does not have a record of the hospital’s request for post-stabilization care via phone or a record that Health Net provided the hospital an authorization for such services.

Required documentation

All requests for authorization, and responses to requests, must be documented. The documentation must include, but is not limited to:

• Date and time of the request.
• Name of the provider making the request.
• Name of the Health Net representative responding to the request.

Conditions of financial responsibility

Health Net is financially responsible for post-stabilization care services that are not pre-authorized, but are administered to maintain, improve, or resolve the member’s stabilized condition if the Plan:

• Does not approve or disapprove a request for post-stabilization care within 30 minutes.
• Cannot be contacted.
• Is unable to reach an agreement with the treating provider concerning the member’s care and a Plan physician is not available for consultation.

If this situation applies, the Plan must give the treating provider the opportunity to consult with a Plan physician. The treating provider may continue with care of the member until a Plan physician is reached or one of the following criteria is met:

• A Plan physician with privileges at the treating provider’s hospital assumes responsibility for the member’s care;
• A Plan physician assumes responsibility for the member’s care through transfer;
• The Plan and the treating provider reach an agreement concerning the member’s care; or
• The member is discharged.

Per the State Medicaid Agency Contract (SMAC) with Department of Health Care Services (DHCS) contracted hospitals and SNFs must use one of the following methods, in a timely manner, to inform the member’s D-SNP and the Medi-Cal plan of any hospital or SNF admission, transfer or discharge. Hospitals and SNFs must use either:

This information must be shared to the extent allowed, under applicable federal and state law and regulations, and not be inconsistent with the member's expressed privacy preferences.

Facilities can identify the member’s Medi-Cal plan by using the State online eligibility system (AEVS).