Requirements for Notification of Utilization Management Decisions

Provider Type

  • Participating Physician Groups (PPG)

Health Net and its participating physician groups (PPGs) to which utilization management (UM) functions have been delegated are required to comply with standards established by the United States Department of Health and Human Services (DHHS), Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Services (DHCS).

All delegated utilization management and denial notifications must be in accordance with Health & Safety Code Section 1363.5 and California Code of Regulations, Title 28, Section 1300.70(b)(2)(H) and (G) and 42 CFR 422.112, 422.152, 422.202 and 422.4.