Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

Health Net uses both externally and internally developed criteria for reviewing cases. These criteria sets create consistency in decision-making by evaluating patient-specific behaviors and symptoms to help make clinically appropriate decisions.

Clinical polices do not constitute a description of plan benefits nor can they be construed as medical advice. These policies provide guidance as to whether or not 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 clinical policy, member benefits, legal and regulatory mandates and requirements, Medicare or Medicaid (as applicable) and any 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.

Clinical policies may have either a Health Net health plan or a “Centene” heading. Health Net utilizes InterQual^® criteria for those medical technologies, procedures or pharmaceutical treatments for which a specific health clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. Clinical policies are reviewed annually and more frequently as new clinical information becomes available.

Behavioral health decisions are based on nonprofit professional association for the relevant clinical specialty including the criteria and guidelines set forth by the Council of Autism Service Providers Criteria and Guidelines, the American Psychological Association Guidelines for Psychological and Neuropsychological Testing and World Professional Association for Transgender Health (WPATH) criteria.

Health Net has implemented the use of the Level of Care Utilization System and Child and Adolescent Level of Care Utilization System (LOCUS/CALOCUS), and the Early Childhood Service Intensity Instrument (ECSII) criteria for all non-ABA (Applied Behavioral Analysis) mental health medical necessity determinations and level of care placement decisions. For ABA decisions, the Council for Autism Services Providers ABA Professional Guidelines are used. For substance use disorder utilization management, Health Net uses the American Society of Addiction Medicine (ASAM) criteria set. When the requested service is not in scope for LOCUS/CALOCUS, or another nonprofit professional association for the relevant clinical specialty, Health Net utilizes internal criteria that have been developed according to generally accepted standards of mental health and substance use disorder care.

By using nationally recognized and evidence-based criteria, our Utilization Managers apply objective, evidence-based standards to support their decisions regarding procedures, levels of care, and continued stay. Supporting appropriate care decisions can lead to better outcomes for our members.

Health Net evaluates each member’s plan of treatment for appropriateness and timeliness. It is Health Net’s policy to share specific level of care guidelines and utilization management review procedures in writing with providers, members, customers, and members of the general public who request them.

Copies of criteria can be obtained for provider and members by calling the specific number listed on the back of the member’s ID card.