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Clinical Criteria for Medical Management Decision Making

Provider Type

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

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

The member's Evidence of Coverage and the Department of Health Care Services (DHCS') Medi-Cal Provider Manual are checked to determine whether the services requested are a covered benefit or if there is specific medical necessity criteria listed in the manual. If there is no medical necessity guidance in the manual, then Health Net's national medical policies are reviewed.

National Medical Policies

As part of Health Net's quality improvement (QI) and utilization management (UM) programs, Health Net's National Medical Policy Department critically reviews published scientific literature to develop evidence-based medical policies. Health Net's medical policies are used as guides for clinical decision-making as they relate to requests for services and/or supplies for our members. The types of medical policies developed include medical necessity clinical criteria, clinical practice guidelines and technology assessment. These policies are designed to assist Health Net medical directors in making utilization review determinations relevant to the effectiveness and appropriateness of medical technology, including services, procedures, devices, medications, techniques, or biologicals.

This determination is based upon the principles of evidence-based medicine and a review of currently available clinical information from peer-reviewed published medical literature, the regulatory status of the technology, public health and health research agencies, guidelines and positions of leading national health professional organizations, views of expert physicians practicing in relevant clinical areas, and other factors. Health Net medical policies are reviewed annually and more frequently as new clinical information becomes available.

The foundation for Health Net policies include nationally recognized sources, such as:

  • McKesson's InterQual® medical necessity criteria
  • Hayes Medical Technology Directory and Hayes Alert technology-based evaluations

MHN, Health Net's behavioral health subsidiary, uses InterQual criteria as the primary source for clinical criteria for making decisions regarding medical necessity.

Health Net evaluates medical technologies based upon principles of evidenced-based medicine. Results of multi-center, randomized, prospective clinical trials published in the peer-reviewed medical literature that show the treatment to be at least as effective or more effective as other established modalities of therapy or associated with fewer adverse effects are considered the most scientifically rigorous evidence. Factors that are taken into account during the evaluation process include, but are not limited to:

  • Whether the procedure, device, medication, technique, or biological has final approval from the appropriate governmental regulatory bodies
  • Whether peer-reviewed scientific evidence is sufficient to permit conclusions about the effect of the technology on health outcomes
  • Whether the technology is capable of demonstrating improvement in overall health outcomes
  • Whether the technology is at least as beneficial as any established alternatives
  • Whether the improvement demonstrated is attainable outside of investigational settings
  • Whether specific clinical situations can be identified under which the technology is used

Health Net's national medical policies are presented to Health Net's National Medical Advisory Council (MAC), which reviews the proposed policies and revises, rejects or approves them. MAC's membership consists of a clinically and geographically diverse group of Health Net medical directors and medical management team representatives. Approved national medical policies are made available to participating providers through the Health Net provider website and to members on the member website.

Medi-Cal utilization management decisions follow guidelines and authorization criteria prepared by the Medical Policy Division of California Department of Health Care Services. In the event a medical policy has not been created, Health Net Medi-Cal refers to guidelines, including Medicare criteria, Health Net's national medical policies and other nationally recognized sources of criteria.

Health Net's national medical polices are developed to assist in administering plan benefits; however, they do not constitute a description of plan benefits nor can they be construed as medical advice. Health Net's national medical 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 medical policy, legal and regulatory mandates and requirements, and any Health Net 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 prepared by Health Net.

Last Updated: 08/06/2021