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Clinical Criteria for Medical Management Decision Making

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

As part of Health Net's quality improvement (QI) and utilization management (UM) programs, Health Net applies a hierarchy of medical resources for making medical management decisions for Cal MediConnect members. Cal MediConnect members are provided access to medically necessary covered services, including all standard Med-Cal fee-for-service (FFS) benefits and all services provided under Medicare Part A, Part B and Part D. Health Net assesses each entity's medical necessity guidelines. For Medi-Cal-specific benefits, the Health Net medical management team uses medical necessity guidelines from Medi-Cal's online Provider Manual, Part 2. For Medicare-specific benefits, the medical management team uses Medicare's guidelines in the Centers for Medicare and Medicaid Services (CMS') National Coverage Determinations, National Coverage Determination Manual, and Local Coverage Determinations documents. In the event one entity provides broader benefits than the other, Health Net applies the broadest benefit when making medical management decisions. When this hierarchy of information does not provide documented coverage guidelines, Health Net's licensed professionals refer to Health Net's national medical policies for evidence-based guidelines.

Health Net's National Medical Policy Department critically reviews published scientific literature pertaining to the efficacy and safety of existing and emerging technologies or new uses of existing technologies. The Medical Policy Department prepares proposed national medical policies designed to assist Health Net medical directors in making utilization review determinations relevant to the effectiveness and appropriateness of medical technology, including services, procedures, devices, medications, techniques, or biologicals. This determination is based upon the principles of evidence-based medicine and a review of currently available clinical information from peer-reviewed published medical literature, the regulatory status of the technology, public health and health research agencies, guidelines and positions of leading national health professional organizations, views of expert physicians practicing in relevant clinical areas, and other factors. Health Net may revise these policies as new clinical information becomes available.

Health Net's National Medical Advisory Council (MAC) reviews proposed medical policies and revises, rejects or approves them. MAC's membership consists of a clinically and geographically diverse group of Health Net medical directors and medical management team representatives. Approved national medical policies are made available to participating providers through the Health Net provider website.

Health Net's national medical policies are used as a guide for clinical decision-making as they relate to requests for services and supplies for members. The policies support Health Net's licensed professionals in making appropriate utilization management or care management decisions. Health Net's national medical polices are developed to assist in administering plan benefits; however, they do not constitute a description of plan benefits nor can they be construed as medical advice. Health Net's national medical policies provide guidance as to whether certain services or supplies are cosmetic, medically necessary or appropriate, or experimental and investigational. The policies do not constitute authorization or guarantee coverage for a particular procedure, device, medication, service, or supply. In the event a conflict of information is present between a medical policy, legal and regulatory mandates and requirements, and any Health Net plan document under which a member is entitled to covered services, the plan document and regulatory requirements take precedence. Plan documents include, but are not limited to, subscriber contracts, summary plan documents and other coverage documents prepared by Health Net.

The foundation for Health Net policies include nationally recognized sources, such as:

  • McKesson's InterQual® medical necessity criteria
  • Hayes Medical Technology Directory and Hayes Alert technology-based evaluations

MHN, Health Net's behavioral health subsidiary, uses InterQual criteria as the primary source for clinical criteria for making decisions regarding medical necessity.

Health Net evaluates medical technologies based upon principles of evidenced-based medicine. Results of multi-center, randomized, prospective clinical trials published in the peer-reviewed medical literature that show the treatment to be at least as effective or more effective as other established modalities of therapy or associated with fewer adverse effects are considered the most scientifically rigorous evidence. Factors that Health Net takes into account during the evaluation process include, but are not limited to:

  • Whether the procedure, device, medication, technique, or biological has final approval from the appropriate governmental regulatory bodies
  • Whether peer-reviewed scientific evidence is sufficient to permit conclusions about the effect of the technology on health outcomes
  • Whether the technology is capable of demonstrating improvement in overall health outcomes
  • Whether the technology is at least as beneficial as any established alternatives
  • Whether the improvement demonstrated is attainable outside of investigational settings
  • Whether specific clinical situations can be identified in which the technology is used
Last Updated: 10/31/2019