In addition to routine data collection, monitoring, evaluation and analysis, the Health Net Delegation Oversight staff is available to assist providers with:

The Delegation Oversight Committee (DOC) meets quarterly and is chaired by the CA Compliance Officer. The purpose of the Delegation Oversight Committee is to provide a forum for discussion of the delegates’ performance and to address significant risks with health plan leadership from various departments.

Topics of the DOC include oversight activities, audit results, corrective actions and recommendations of the Delegation Oversight Workgroup (DOW) which is a subcommittee led by the Delegation Oversight team. As needed, the DOC will discuss remedial actions such as increasing oversight or revoking delegation.

The Delegation Oversight team has established issue management processes with escalation steps to address continued substandard performance with health plan policies, contractual obligations and/or regulatory requirements.

Steps include discussions with delegates during Joint Operations Meetings (JOMs) and leadership discussions via DOW and DOC. Our Delegates’ ongoing performance with plan policies, contractual obligations and regulatory requirements is shared with leadership through monthly reporting and discussed during DOW, DOC and ad hoc escalation meetings.

The Health Net Member Services or Appeals & Grievances departments work to resolve individual member complaints. All member complaints and inquiries are entered into Health Net’s Appeals & Grievances System of records for tracking, and reports are generated quarterly to allow for tracking and profiling within and between providers. The quarterly complaint report aggregates the type of complaint by PPG and by region. Health Net's Credentialing Committee, regional medical directors (RMDs), the Delegation Oversight director, and Quality Improvement (QI) staff review the reports that are sent quarterly to the Quality Improvement Health Equity Committee (QIHEC). A corrective action plan (CAP) is implemented, if necessary, and tracking and follow-up evaluations continue to monitor the success of the action plan.

Member complaints with potential quality of care issues are reviewed by the Health Net Clinical Appeals & Grievances Department as part of the appeals and grievances process, which conducts an investigation of each issue and tracks trends for quality of care issues by provider, PPG and type of issue. Provider-specific cases are prepared and presented to the Health Net Peer Review Committee for review and action.

During the investigation of potential quality of care issues, the QI specialist may request additional information, medical records or implementation of provider-specific action plans from the PPG. Noncompliance with these requests may lead to sanctions, such as freezing enrollment of Health Net members until the issue is resolved or possible termination of the Health Net contract.

Health Net provides feedback to PPGs on their preventive care services, in an effort to encourage delivery of such services. Techniques include quality of care and service report cards, discussions at physician forums, onsite meetings with PPG staff, and financial incentives to increase the amount of preventive care services. Member education is also part of this effort.

Health Net requires that PPGs and participating primary care physicians (PCPs) follow the clinical practice guidelines recommended by the United States Preventive Services Task Force (USPSTF), the American Congress of Obstetrics and Gynecology (ACOG), the American Cancer Society (ACS), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) in the treatment of Health Net members. A Health Net member's medical history and physical examination may indicate that further medical tests are needed. As always, the judgment of the treating physician is the final determinant of member care.

Refer to the preventive care guidelines discussion under the Benefits topic for more information.

If a participating provider needs to request a change to the information currently in their Health Net Provider Participation Agreement (PPA), the request must be made in writing. The request can be made in one of the following ways:

The request should be sent to Health Net's main corporate address.