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Utilization Management Goal

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

The goal of the Health Net Utilization Management (UM) and care management (CM) programs is to provide members with access to the health services delivery system in order to receive timely and necessary medical care in the correct setting. Health Net's UM and CM programs comply with all applicable federal and state laws, regulations and accreditation requirements. The UM system is also intended to analyze and measure effectiveness while striving for improvement of services. Health Net's UM system separates medical decisions from fiscal and administrative management to assure that medical decisions are not unduly influenced by fiscal and administrative management.

Health Net gathers encounter data from participating physician groups (PPGs) (if applicable) and data from the Health Net Medical Management System to monitor potential indicators over- and under-utilization. Based on the classification of delegation, the following types of data are collected:

  • System-wide data:
    • Member services complaints
    • Member satisfaction surveys
    • PPG transfer rates
  • PPG data:
    • Encounter data
    • Unity system reports (such as Monthly Census and Detail reports)
    • PPG report card (profile reports of utilization statistics)
    • UM denial and appeal logs
Last Updated: 07/01/2024