Quality Management Program and Resources
Health Net’s quality management program continuously monitors and evaluates the quality, appropriateness and outcome of care and services delivered to our members. It includes the development and implementation of standards for clinical care and service, measurement of compliance to standards, and the implementation of actions to improve performance.
Below is an overview of the components of the multifaceted quality management program. It includes quality improvement (QI) processes and instructions on how to get more information from the Health Net provider website.
Open clinical dialogue
Health Net practitioners and providers are encouraged to talk freely with members about their medical conditions, treatment options and medications, regardless of limits to coverage.
Health Net unifies programs, from wellness to complex care, reflecting our commitment to a whole-person strategy. Members who qualify have access to wellness programs for obesity prevention, smoking cessation, pregnancy support, and chronic conditions management.
Decision Power program
The Decision Power program offers a health management solution to improve members’ health and quality of life. Through personalized interventions and contemporary behavior change methodologies, Health Net’s experienced staff can help members at risk and diagnosed with chronic health conditions to better manage their conditions through education, empowerment and support. Decision Power includes a suite of programs and support encompassing health and wellness, integrated care management, case management, and women’s and children’s health.
Decision Power wellness programs
Health Net offers many tools and programs to help members adopt and maintain healthy lifestyles, such as:
- RealAge® test (health assessment) – An online interactive tool that helps members identify health risks based on current lifestyle behaviors and family history. Members are provided a summary of their results that can be printed and shared with their physicians.
- Health profile – An online secure database where members can track important medical history, including health conditions, immunizations, medications, tests, and procedures. Information from theRealAge test automatically becomes part of their personal health profile.
- Online wellness resources – Offers a flexible way to improve health and wellness – on the member’s own terms. The content library has a variety of physical, emotional, social, financial health, and clinical materials. This consists of numerous articles and videos that relate to healthy weight, improving your diet, stress management, tobacco cessation, and more. Examples of some of our online wellness resources include health articles, trackers, health videos, and health challenges.
- Lifestyle management (health coaching) – One-to-one telephonic health coaching provides extra help individuals need; online health coaching and resources provide additional support to members. A personal health coach helps with short- and long-term goal setting and achievement for lasting results. The program includes trackers and easy tools to use in the behavior change process. Personalized health coaching is available for weight loss, healthy eating, stress management, exercise, and tobacco cessation. Additional program and enrollment information is available on Health Net under Wellness Center.
- Tobacco cessation program – Telephonic and online support with a quit coach. Individuals receive one-to-one help during their quit process and unlimited access to online education and coaching support. Additional program and enrollment information is available online at Health Net underWellness Center.
- Decision Power® healthy discounts – Health Net members have access to exclusive discounts on eye care, vitamins, herbs and supplements, health clubs, and other health-related products and services, including discounts with Jenny Craig® and WW® (Weight Watchers).
- Health challenges – Online challenges to help individuals achieve small changes related to healthy eating, exercise, stress management, and weight loss. The health challenges offer focused behavior change strategies and record keeping to help participants stay on track for success.
- Tools, such as decision aids and a symptom checker, to help members understand their health plan options so that they can choose what is best for them and their families.
Chronic conditions management
The Integrated Care Management program addresses the physical, behavioral and psychosocial needs of the member as part of Health Net’s Population Health Management. The program supports members, families and caregivers by assisting members in achieving optimum health, functional capability and quality of life through improved management of their disease or condition.
Management of chronic conditions (diabetes, asthma and chronic obstructive pulmonary disease (COPD)) and cardiac conditions (heart failure, coronary artery disease and hypertension) is incorporated into the Integrated Care Management program.
Health Net offers participants and their providers the programs, tools, connectivity, and information to make better health care decisions to:
- Slow the progression of the disease and the development of complications through proven program interventions.
- Change behaviors and improve lifestyle choices by using demonstrated behavior change methodologies.
- Improve compliance with guidelines and the member’s plan of care.
- Manage medications and enhance symptom control.
- Educate members regarding recommended preventive screenings and tests according to national clinical guidelines.
- Encourage the correct use of medications to prevent medication errors.
Providers and members may contact their designated care manager for additional assistance with chronic conditions management.
Care reminder messages are sent when potential gaps in care are identified through claims, laboratory data and other sources. These reminders aim to help specific individuals take action and to align with industry-recognized HEDIS measures to improve preventive health, chronic condition management and more.
Health Net care gap reports are available monthly to providers and accompanied by a HEDIS report card so that medical groups can track their performance compared to national benchmarks.1 On the member side, Health Net uses the care gap information to send out messaging in modes members prefer, including text messaging, emails, live calls with a clinical pharmacist, and mailings.
1 Care gaps are refreshed twice monthly and pushed to participating primary care physicians (PCPs) via the Cozeva® provider portal.
The Pregnancy Program incorporates the concepts of case management, care coordination, disease management, and health promotion. The program helps teach pregnant members how to have a healthy pregnancy and first year of life for babies. It also aims to reinforce the appropriate use of medical resources to extend the gestational period, reduce the risks of pregnancy complications, premature delivery, and infant disease. Members can participate by calling Member Services at the phone number on the back of their card.
Powered by findhelp, formerly known as Aunt Bertha, Health Net Community Connect offers the largest online search and referral platform. There are 10 topics to choose from, such as food, housing and transportation. Then select a subtopic which will contain a list of services based on the ZIP Code entered. The results can be viewed in over 100 languages. To use the tool, go to Health Net Community Connect, take the Social Needs Assessment, enter a ZIP Code and click on Search.
Health Net’s Integrated Care Management (ICM) program provides whole person-centered care that addresses the member's medical, mental and psychosocial needs. The ICM program targets the most complex cases, often with life-limiting diagnoses, and assist members who have critical barriers to their care. Trained Registered Nurses and Licensed Clinical Social Workers provide case management services to Health Net members, their families and caregivers as needed. These members may have multiple comorbid conditions and need assistance in planning, managing and executing their care.
Health Net conducts utilization surveillance and uses predictive modeling tools to identify appropriate members for this program; however, providers may also become aware of a severely ill Health Net member not currently enrolled in this program who may benefit from integrated case management services. Providers should use the criteria below when considering whether to refer a member to the Health Net integrated case management program.
It is appropriate to refer Health Net members with the following complex concerns to this program for evaluation:
- Moderate to late stage cancer, neurological, circulatory, endocrine, respiratory conditions, and uncontrolled pain/uncontrolled symptomology.
- Multiple care providers who may not be communicating with each other, which increases the risk of an acute event, such as hospital readmission.
- Advanced chronic diseases with multiple hospitalizations (greater than two in the last six months).
- Experiencing significant symptoms and side effects that could lead to an emergency room visit or hospitalization.
- Problematic or unstable comorbidities.
- Rare conditions requiring more extensive education, care coordination and support.
- Member seeking alternative therapeutic options, using out-of-network facilities and providers.
- Clinical trials.
- Active terminal care issues.
- High utilization of expensive resources, including multiple admissions or frequent emergency room visits.
- Complex support and caregiver needs.
- Acute uncontrolled symptoms of disease process or treatment.
- High degree of coordination, integration, referrals, and planning needed.
- Social determinant issues which may include:
- No support system or inadequate support system that is unable to cope without intervention.
- Caregiver burnout.
- Unsafe environment.
- Significant financial difficulties.
In addition, providers should consider the questions below to determine whether the member has one or more of the following issues that cannot be managed by the provider’s office or treating specialists:
- Does the member have a terminal diagnosis or prognosis and struggle with whether to proceed with aggressive or palliative treatment?
- Is the member experiencing significant problems due to disease-related pain and symptom control, such as fatigue, anxiety, nausea, constipation, dyspnea, or depression?
- Does the member live in an unsafe environment?
- Does the member have significant financial issues?
- Does the member have multiple providers of care who may not be communicating, which creates an ongoing risk for an acute event, such as readmission?
- Has the member developed severe, complicated comorbidities?
- Does the member have an inadequate support system or is the primary caregiver suffering from burnout?
- Is the member frequently using the emergency room to obtain their care?
If a Health Net member meets any of these criteria, providers may contact the Health Net Case Management Department. Members who want to self-refer to this program may call the toll-free Customer Contact Center number on the back of their Health Net identification (ID) cards. The Customer Contact Center representative contacts the Case Management Department with the member’s information for appropriate outreach. Contacting the Case Management Department does not automatically qualify the member for the Health Net integrated case management program.
The nurse advice line provides appropriate and timely triage for health-related problems through registered nurses (RNs) utilizing industry-approve guidelines and protocols. Using nationally recognized algorithms and world-class clinical triage guidelines, nurse advice line RNs identify member needs and ensure they are directed to the appropriate level of care for the situation – whether it is providing self-care guidance, or recommending a visit to urgent care or the ER. The service is offered 24 hours a day, seven days a week, 365 days a year in English and Spanish with translation services available for other languages.
Clinical practice guidelines
Health Net’s evidence-based clinical practice guidelines are updated at least every other year and when new scientific evidence or national standards are published. Centene’s Corporate Clinical Policy Committee and/or Health Net’s Medical Advisory Council (MAC) adopt the clinical practice guidelines and tools, which are available on the Health Net provider portal. Providers who do not have access to the Internet may contact the Health Net Provider Services Center to request printed copies of these guidelines.
Guideline sources include, but are not limited to, the following:
- Chronic conditions management – Decision Power clinical guidelines are available for providers to quickly reference information about a number of chronic conditions, which include asthma, COPD, CAD, diabetes, and HF. Sources are found within the guidelines.
- Behavioral health – Clinical guidelines are available for such disorders as attention deficit hyperactivity disorder (ADHD) and substance use disorder.
Preventive care guidelines
Health Net provides coverage for preventive care on our commercial individual and family, small and large group plans, in accordance with the requirements of the Affordable Care Act (ACA). Preventive care refers to services or measures taken to promote health and early detection or prevention of diseases and injuries, rather than treating or curing them. Preventive care includes, but is not limited to, immunizations, medications, contraception, tobacco cessation treatment, examinations and screening tests tailored to an individual’s age, health and family history. According to the ACA, preventive care services must include the following:
- Evidence based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF).
- Immunizations for routine use in children, adolescents and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC).
- With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
- With respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the HRSA.
As new preventive care recommendations/guidelines are released by the USPSTF, ACIP and HRSA, they are reviewed and shared with Centene’s ACA Preventive Policy & Benefit Administration Committee for implementation needs.
Note: All newly released preventive care recommendations/guidelines must be applicable to group health plans and health insurance issuers for plan years (in the individual market, policy years) that begin on or after the date that is one year after the date the recommendation or guideline is issued.
For the most up-to-date information pertaining to preventive care coverage requirements, visit these websites:
Health Net uses utilization management (UM) decision-making criteria that are objective and based on medical evidence to determine medical necessity, including InterQual®, Hayes Medical Technology Directory, Medicare coverage determinations, and Centene clinical policies and Health Net medical policies.
MHN, Health Net’s behavioral health administrator, conducts utilization review of covered health care services and benefits for the diagnosis, prevention and treatment of mental health and substance use disorders. This includes children, adolescents and adults. MHN applies the criteria and guidelines from the most recent versions of treatment criteria developed by the nonprofit professional association for the relevant clinical specialty including:
- American Society of Addiction Medicine.
- Child and Adolescent Level of Care Utilization System.
- Early Childhood Service Intensity Instrument.
- Level of Care Utilization System.
Centene and Health Net medical policies are available to providers on the Health Net provider portal.
When a medical necessity decision results in a denial, the denial letter contains an explanation of the denial, the criteria used to make the decision and appeal rights. The letter also includes the contact name and phone number of the Health Net medical director if the requesting provider needs to discuss the denial.
Practitioners and providers participating with a Health Net delegated partner may also contact the delegated partner’s UM department for the UM criteria. Health Net UM staff are available by contacting the Health Net Provider Services Center. The delegated partner UM staff can be contacted through the delegated partner.
UM decisions are based only on appropriateness of care, service and existence of coverage. Health Net does not reward practitioners, providers or other individuals for issuing denials of coverage for health care or services. There are no financial incentives for UM decision-makers to encourage decisions that result in underutilization.
The Quality Improvement Department utilizes several specific quality initiatives to help improve member health outcomes. Members may receive general or targeted outreach through mailings, emails, text messages, live or automated calls providing them with important educational information or reminders to take action when necessary. The focus of these initiatives may include preventive health screenings, influenza and vaccines, chronic disease management, and medication management. Outreach may be conducted by qualified vendors contracting with
Health Net also collaborates with the California Quality Collaborative (CQC) to facilitate the sharing of ideas, best practices and resources. Various programs are available to providers to improve chronic disease care, patient satisfaction and efficiency. For a listing of educational programs and patient satisfaction and condition management resources, providers can visit CQC.
Medicare Star Ratings
Improving quality of care is of primary importance for the Centers for Medicare & Medicaid Services (CMS) and one method it uses to monitor plans to ensure they meet Medicare’s quality standards is the Medicare Star Ratings. This system is also used by CMS to tie improved quality of care for MA beneficiaries to quality bonuses. The ratings provide a tool for Medicare members to compare the quality of care and customer service offered by MA health and pharmacy plans. It is important that providers participate in and promote QI initiatives to improve the quality of care provided to MA members. Provider activities to help meet the goals of these QI initiatives include:
- Ensuring patients are up to date with all preventive health screenings.
- Developing or using registries to improve chronic disease management.
- Identifying patients with gaps in care and providing follow-up calls or letters.
- Conducting comprehensive annual exams to monitor medications, document care needs, review care plans, determine functional status, and identify social and physical needs (including pain status), and barriers they may have to routinely taking their medications.
- Coding claims and encounters accurately for the best data capture.
- Distributing educational materials to patients to help them understand and recall discussions, and improve compliance with their treatment plans.
Quality measures and suveys
Health Net measures quality of care and services provided to members in a number of ways, including HEDIS for performance measures for care and service, CAHPS® for annual assessments of member satisfaction and the Health Outcomes Survey (HOS®) for Medicare members.
PPGs participating in Health Net’s Pay for Performance (P4P) program for commercial plans receive annual reports, known as P4P Report Cards, which reflect effectiveness of care and member satisfaction.
The information gathered from members, practitioners and providers enables Health Net to address opportunities for improvement and are the basis for the implementation of various QI initiatives. Health Net performance results for many of these efforts are available online through the provider portal or by mail on request. Refer to the Additional information section at the end of this update. It lists which provider portal to access based on the line of business.
Quality and safety reporting
Health Net offers WebMD’s Hospital Advisor tool, which provides hospital-specific performance information by diagnosis or procedure, and features metrics including volume, cost, mortality, and complication rates. Data are based on a variety of sources, such as state figures and reporting from The Leapfrog Group, CMS hospital quality indicators, and patient satisfaction information. This online tool is available to members and providers to support informed decision-making when choosing a site for care. Go to the Health Net provider portal. Find the Quick Links section and click on QI Corner Tools & Resources. Then select Compare Hospital tool under Provider Resources.
The Leapfrog Group
The Leapfrog Group is an organization founded to promote patient safety and improve quality of care. Since 2014, Health Net has been a Leapfrog Partner and actively works with Leapfrog and its partners to improve the safety and quality of care. Health Net serves as co-chair of Leapfrog’s Partners Advisory Committee and participates in its Data Users Group.
Health Net’s work as a Leapfrog Partner includes promoting participation in the Leapfrog hospital and ambulatory surgery center (ASC) surveys, which offer consumers key information about a facility’s quality and safety performance with respect to established patient safety practices and progress toward national quality standards. Examples of hospital survey measures include:
- Computerized physician order entry (CPOE).
- Intensive care unit (ICU) physician staffing.
- Evidence-based hospital referral.
- Safe practices score based on National Quality Forum (NQF) standards.
Participation in Leapfrog’s surveys offer hospitals and ambulatory surgery centers (ASCs) the ability to assess their strengths and weaknesses in areas such as hospital-acquired condition scores and evidence-based care to address common acute conditions.
In addition to making these survey findings publicly available, Leapfrog publishes a Hospital Safety Grade. This composite score assigns individual hospitals a letter grade to indicate hospital performance on patient safety according to an analysis of up to 27 quality measures. For more information, visit The Leapfrog Group.
Office of the Patient Advocate
The California Office of the Patient Advocate (OPA) rates health plans and medical groups in their Health Care Quality Report Cards. The Report Cards allow consumers to compare the quality of care. The quality information includes clinical as well as patient experience data and is available on the Health Net provider portal. Select Medical Group Report Card under Provider Resources.
Health Net providers must utilize contracted transplant and bariatric performance centers for all members qualifying for these procedures to promote the best clinical outcomes and coordination of care. These performance centers and their participating surgeons have been selected based on adherence to national guidelines and accredited requirements, and have demonstrated an ongoing commitment to improving surgical performance and patient outcomes. The performance centers are also expected to coordinate a seamless transition of care by sharing information and keeping PCPs informed of their patients’ status. Lists of transplant and bariatric performance centers are available in the Provider Library > Operations Manual >Benefits > Bariatric Surgery or Transplants.
As appropriate, PCPs provide care for Health Net members who have behavioral health diagnoses. Health Net also offers behavioral services from MHN providers. Practitioners and providers may refer members for behavioral health services or members can self-refer by calling MHN at the phone number on their Health Net ID cards.
For routine behavioral health service requests, MHN notes the member’s needs, geographic area, benefit plan, and scheduling requirements to identify a practitioner or program that meets the clinical needs of the member. Member preferences, such as gender and cultural experience, are considered whenever possible. MHN’s standards make services available within six hours for non-life-threatening emergencies, within 48 hours for urgent situations, within 10 business days for routine services with a non-physician mental health provider, and 15 business days with a psychiatrist.
PCPs and their office staff may contact MHN customer service and speak with a licensed care manager (CM). Patients must sign an Authorization for Disclosure form before the PCP or office staff speaks to an MHN CM. For physicians who need help finding appropriate behavioral health care for their members, MHN customer service representatives can answer questions about MHN, its network of practitioners and programs, the referral process, member eligibility and benefits.
Coordination of care is fundamental to the member’s well-being. PCP offices that receive information from other medical or behavioral health specialists are encouraged to document the information in the member’s medical record and review relevant information with the member at his or her next primary care visit.
Screening for depression
Practitioners and providers are encouraged to screen members for depression and other behavioral health conditions. Various brief screening instruments are available, such as the Patient Health Questionnaire (PHQ-9) from the U.S. Preventive Services Task Force. There is no cost to users and it is available in English and more than 30 other languages. Newly enrolled Medicare members are screened for depression through a health risk assessment (HRA).
Health Net offers medication reminders and educational messages for adult commercial and MA members identified with depression. Members newly prescribed with an antidepressant medication receive automated IVR calls. The calls also offer a phone number to call a pharmacist if there are any medication-related questions. The call also offers a live transfer to MHN, if members would like to talk to a psychiatrist, therapist, or other behavioral health provider about their medicine.
Most Health Net members appropriately seek depression treatment from their PCPs, which is why Health Net provides physicians and PPGs with the following tip sheets to manage and coordinate care for their patients with depression. Go to Health Net website and select Provider Tip Sheets, then select:
- Antidepressant Medication Management – AMM Tip Sheet.
- Behavioral Health (BH) Information Exchange to Help Improve Outcomes – BH Information Exchange.
- Depression Screening and Follow-Up – CDF, DSF Tip Sheet.
MHN Outreach program
The QI Department utilizes several specific quality initiatives to help improve members’ physical and mental health outcomes. The health plan has collaborated with MHN on quality improvement activities that may reach your office or practices. Note for Medicare Advantage members: Any reference to prescribing ADHD medication to children does not apply.
Overall, members and providers may receive live calls from MHN’s quality team, providing members and providers with important educational information or reminders to take action when necessary. The focus of these initiatives may include antidepressant medication management, follow-up for children prescribed ADHD medication, and coordinating referrals and care. Below is a summary of the collaborative quality improvement projects:
MHN telephonic outreach to:
- Families with children who are prescribed ADHD medication.
- Physicians who are prescribing ADHD medication, or other types of psychotropic medications.
- Members about antidepressant medication management and the importance of coordination of care.
MHN written outreach to:
- Physicians about antidepressant medication management and the importance of coordination of care.
Alcohol and substance use
In collaboration with MHN to help improve the diagnosis, treatment and follow-up care of alcohol and other drug (AOD) use, Health Net has included information about signs, symptoms and PCP management in the following tip sheets. Go to Health Net Provider Library, select Education, Training and Other Materials, then select:
- Alcohol and Other Drug Treatment – IET Tip Sheet.
- Behavioral Health (BH) Information Exchange to Help Improve Outcomes – BH Information Exchange.
- Follow-up after an Emergency Department Visit for Mental Illness (FUM) / Follow-up after an Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA) – FUM/FUA Tip Sheet.
Providers have access to MHN’s customer service line by dialing the MHN number on the back of the member’s ID card or by dialing 888-935-5966 for help finding appropriate care for members, information about the referral process, member eligibility, and benefits.
Health Net and Centene Pharmacy Services, the Pharmacy Therapeutics (P&T) Committees and the Centene Strategy Development Committee (SDC) manage the Health Net formularies. These documents are available to participating providers and members through Health Net. The Health Net formularies serve as references for providers to use when prescribing pharmaceutical products for Health Net members with pharmacy coverage. The Health Net formularies are available on the Health Net provider portal. Then select Drug Information for Commercial Plans under Drug Lists. The Health Net P&T Committee consists of actively practicing physicians and pharmacists. The committee reviews medications based on clinical efficacy, safety, side effects, cost-effectiveness, quality outcomes, and comparisons to existing products.
The committee also develops protocols for medications requiring prior authorization. Considerations include benefit plans and exclusions, step-care protocols, quantity or duration limits, and potential for misuse. Other considerations are potential usage indications that do not meet U.S. Food and Drug Administration (FDA) criteria, experimental or off-label use, and required level of laboratory or safety monitoring. The medication list and usage guidelines are reviewed and updated quarterly by the P&T Committee.
Prescribing practitioners receive information quarterly when updates occur that include:
- A list of pharmaceuticals with restrictions and preferences.
- How to use the pharmaceutical management procedures.
- An explanation of quantity limits.
- How prescribing practitioners must provide information to support an exception request for formulary, non-formulary and step therapy.
- The process for generic substitution and step therapy protocols.
The Centene Pharmacy Services and the SDC may recommend cost-based tier placement in the formularies for medications determined to be clinically equivalent by the P&T Committee.
Appropriate Opioid Utilization Initiative
The Appropriate Opioid Utilization Initiative’s objectives are to reduce opioid overutilization, promote appropriate opioid use by members, enhance coordination of care between prescribers, and decrease the use of opioids after filling a prescription for opioid dependence. In addition, the program offers strategies and tools to providers for proper pain assessment and treatment of Health Net members.
Health Net sends targeted providers a biannual mailing, including a letter, medication reviews of members identified as having a high use of narcotic medications (greater or equal to 90 MME per day) and notifies all prescribers. A Health Net pharmacist directly outreaches to members to educate and counsel on the risks of taking high dose opioids, signs of opioid overdose and proper usage of Naloxone in case of overdose.
Health Net strives to ensure compliance with all applicable state, federal, regulatory, and accreditation requirements to provide members with timely access to care. Health Net regularly monitors the network and evaluates whether members have enough access to practitioners and providers who meet their care needs.
Health Net notifies all applicable providers about Health Net’s established appointment access standards, network adequacy requirements, and access and availability monitoring processes. The standards include, but are not limited to, appointment waiting times for routine, urgent and preventive care; requirements for after-hours access to care; and other requirements and guidelines for access to medical care as mandated by the applicable regulatory body for the line of business.
The complete set of access standards and revised after-hours script templates are available in the Health Net Provider Library. Select Provider Manual > Provider Oversight > Service and Quality Requirements > Access to Care and Availability Standards. Providers who do not have access to the Internet may contact the Health Net Provider Services Center to request printed copies of these standards and after-hours script templates.
Health Net is committed to treating members in a manner that respects their rights, recognizes their specific needs and maintains a mutually respectful relationship. In order to communicate this commitment, Health Net has adopted member rights and responsibilities. These rights and responsibilities apply to members’ relationships with Health Net, its practitioners and providers, and all other health care professionals providing care to its members. Member rights and responsibilities statements are distributed to new practitioners when they join the network and to existing practitioners, if requested.
In compliance with regulatory requirements and to ensure members receive the highest quality of care (QOC), Health Net monitors and evaluates potential quality of care issues involving Health Net members through the Health Net quality management program. QOC incidents may include, but are not limited to, the following:
- Practitioner/provider denies necessary service(s) to member.
- Concerns that care provided did not meet professionally recognized standards of healthcare.
- Member exposed to serious harm.
- Appropriate care provided but member experienced adverse outcomes.
- Neglect or physical, mental, or psychological abuse.
- Testing/assessment insufficient, inadequate, or omitted.
- Concerns about prescriber, medications, or medication management.
Potential Quality Incident Referral Form
Providers can complete the Potential Quality Incident Referral Form located on Archer within the Potential Quality of Care Incident Policy and submit it to the Grievance Department, preferably within one business day of the incident. The indicators on the form refer to an event or trigger. Use the broad general category lists to identify the potential quality of care issue, or use the Other category to describe the incident. Additional completion instructions are provided on the form.
A member or a member representative who believes that a determination or application of coverage is incorrect has the right to file an appeal. Health Net responds to commercial standard appeals within 30 calendar days. A 72-hour appeal resolution is available if waiting could seriously harm the member’s health.
In addition to this appeal process, HMO, POS and HSP members may also contact the California Department of Managed Health Care (DMHC). DMHC is responsible for regulating managed health care service plans. DMHC receives complaints and inquiries about health plans via a toll-free number at 888-466-2219. The hearing and speech impaired may contact DMHC at 877-688-9891 (TDD). DMHC’s complaint forms and instructions are available online via the DMHC website. EPO and PPO members may contact the California Department of Insurance (CDI) by phone at 800-927-4357 or online.
Health Net does not delegate member grievances or appeals. All grievances and appeals must be forwarded within one business day to the Health Net Appeals and Grievances Department.
Appeals and grievances PPG reports
Health Net has added a written record of commercial HMO and POS appeals and grievances to the quarterly PPG-specific performance reports. Metrics contained in these reports are benchmarked against overall health plan experience, and detail is provided for both clinical and administrative appeals. This may reveal opportunities at the PPG level to improve management of appeals and grievances with the ultimate goal of enhancing the customer experience, decreasing the overturn volume and improving the denial process.
Health Net members’ protected health information (PHI), whether it is written, oral or electronic, is protected at all times and in all settings. Health Net practitioners and providers can only release PHI without authorization when:
- Needed for payment.
- Necessary for treatment or coordination of care.
- Used for health care operations (including, but not limited to, HEDIS reporting, appeals and grievances, UM, QI, and disease or care management programs).
- Where permitted or required by law.
Any other disclosure of a Health Net member’s PHI must have a prior, written member authorization.
Health Net practitioners and providers must ensure that only authorized people with a need to know have access to a member’s PHI. Health Net requires PPGs to obtain Health Insurance Portability and Accountability Act (HIPAA) Business Associate agreements from people or organizations with which the PPG participates to provide clinical and administrative services to members.
Special authorization is required for uses and disclosures involving sensitive conditions, such as psychotherapy notes, AIDS or substance abuse disorder (SUD). To release a member’s PHI regarding sensitive conditions, Health Net practitioners and providers must obtain prior written authorization from the member (or authorized representative), which states the information specific to the sensitive condition that may be disclosed.
Interpreter services are available 24/7 at no cost to Health Net members and providers without unreasonable delay at all medical points of contact. The member has the right to file a complaint or grievance if linguistic needs are not met.
- Providers may not request or require an individual with limited English proficiency (LEP) to provide their own interpreter.
- Providers may not rely on staff other than qualified bilingual/multilingual staff to communicate directly with individuals with LEP.
- Providers may not rely on an adult or minor child accompanying an individual with LEP to interpret or facilitate communication.
- A minor child or an adult accompanying the patient may be used as an interpreter in an emergency involving an imminent threat to the safety or welfare of the individual or the public where there is no qualified interpreter for the individual with LEP immediately available.
- An accompanying adult may be used to interpret or facilitate communication when the individual with LEP specifically requests that the accompanying adult interpret, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.
- Providers are encouraged to document in the member’s medical record the circumstances that resulted in the use of a minor or accompanying adult as an interpreter.
To obtain interpreter services, members and providers can contact Health Net Member Services at the phone number located on the member’s ID card. Request in-person interpreters, including sign language interpreters, a minimum of five business days before the appointment during business hours.
Please allow for video remote or a phone interpreter if that is the only option available for the language, date and time of the appointment.
Health Net has established standards for the administration of medical records that ensure medical records conform to good professional medical practice, support health management and permit effective member care. A good medical record management system provides support to clinical practitioners and providers in the form of efficient data retrieval. It also makes data available for statistical and quality-of-care analyses.
The medical record serves as a detailed analysis of the member’s history, a means of communication to assist the multidisciplinary health care team in providing quality medical care, a resource for statistical analysis, and a potential source of defense support information in a lawsuit. It is the practitioner’s and provider’s responsibility to ensure completeness and accuracy of content, as well as the confidentiality of the health record. Health Net requires that the practitioner and provider adhere to the standards for maintaining member medical records and to safeguard the confidentiality of medical information.
Practitioners and providers are responsible for protecting the confidentiality interests of Health Net members when responding to requests for information. All practitioners and providers must have policies and procedures that address confidentiality and the consequences of improper disclosures of member PHI. Refer to the Medical Records Guidelines topic in the Health Net provider operations manuals to review specific levels of medical record security that must be addressed by practitioner and provider policies and procedures governing the confidentiality of medical records and the release of member PHI.
Health Net monitors medical record documentation compliance and implements appropriate interventions to improve medical record-keeping. Medical record guidelines are available through the original website at provider.healthnet.com or upon request by contacting the Health Net Provider Services Center.