Requirements for Notification of Utilization Management Decisions
Provider Type
- Physicians and Practitioners
- Hospitals
- 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 timeliness standards for UM decisions and notifications. Health Net has adopted the timeliness standards approved by the Health Industry Collaboration Effort (HICE) and the National Committee for Quality Assurance (NCQA).
For current standards, refer to the HICE website at www.iceforhealth.org/home.asp to locate the Approved HICE Documents for the commercial and Medi-Cal ICE UM Timeliness Standards.
The National Committee for Quality Assurance (NCQA) counts the time from the date when Health Net receives the request, regardless of whether it is during business hours. Non-urgent requests may be processed on the next business day. Refer to Notification Delays for notification timelines when expert consultation is required to made the initial decision.