- Participating Physician Groups (PPG)
Financial penalties may be imposed on Health Net by regulators if specified time limits are not met. Reasonable delays include Health Net or the participating physician group (PPG) with delegated utilization management (UM) functions experiencing the following:
- Have not received requested information reasonably necessary to determine the medical necessity of the services requested
- Requires a consultation with an expert reviewer
- Have requested an additional examination or test on the member (provided the test is reasonable and consistent with good medical practice)
Health Net or PPGs with delegated UM functions are required to notify both the provider and member in writing about the delay, either immediately on expiration of the allowed time or as soon as Health Net or the PPG with delegated UM functions becomes aware that it will not meet the time requirement, whichever comes first. The provider must also be notified initially by telephone. Refer to the Health Industry Collaboration Effort (HICE) website to obtain the ICE Notice of Action (NOA) template located under Approved ICE Documents. The notification delay letter must include the reason for the delay, specific information pertaining to the additional information or consultation being requested, and the anticipated date of the decision. Once the additional information is received, the same time limits apply.