Clinical Criteria for Utilization and Care Management Decisions
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
To determine medical appropriateness, the Health Net utilization management (UM)/care management (CM) program uses recognized guidelines and criteria sets that are clearly documented, based on sound clinical evidence, and include procedures for applying criteria based on the needs of individual members and characteristics of the local delivery systems.
For the Medi-Cal program, Health Net uses criteria set forth in applicable sections of Titles 17 and 22 of the California Code of Regulations, Department of Health Care Services (DHCS) Managed Care All Plan Letters, DHCS Medi-Cal Provider Manuals, and Hayes evidence-based resources.
These criteria are used to appropriately and consistently evaluate clinical services for medical necessity when approving, modifying or denying requests for services. Health Net also uses InterQual® Care Planning Criteria along with other company-wide evidence-based medical policies, which are approved and updated by the Health Net Medical Advisory Council (MAC).
These UM criteria guide the assessment of medical necessity for pre-service outpatient requests, admissions and concurrent stay review in acute and skilled facilities. If conflicting criteria exist, Health Net considers Title 22 to prevail.
When applying criteria to a specific individual case, Health Net considers at least the following factors:
- Age
- Comorbidities
- Complications
- Progress of treatment
- Psychosocial situation
- Home environment, when applicable
- Characteristics of the local delivery system (if clinically necessary care is not available within the local delivery system, Health Net assists the member and practitioner to determine an alternate appropriate delivery system):
- Ability of local hospitals to provide all recommended services within the estimated length of stay
- Availability of skilled nursing facilities or subacute care facilities
- Availability of other care appropriate to meet the member's individual needs
To ensure that the criteria used are consistently current, Health Net at least annually:
- Renews license agreements for the latest versions of the appropriate criteria sets, clinical practice guidelines and technology assessments
- Analyzes and updates medical criteria changes based on information collected from the previous year
The Health Net MAC and Quality Improvement and Health Equity Committee (QIHEC) are responsible for the review, revision and approval of all criteria.
Health Net makes many of the clinical criteria sets, including Health Net's medical policies, available to participating providers.