Concurrent review (CCR) is the ongoing evaluation of the medical necessity, appropriateness, and continued need for inpatient services while care is being rendered.

CCR is initiated upon notification to the Health Net Medical Management Department that a member has been admitted. CCR review includes an evaluation of:

Based on the CCR process, the inpatient stay is approved or denied. If the stay is approved, the facility receives an authorization number. The authorization number must be indicated on the facility claim to Health Net.

All potentially denied services identified by the Health Net utilization management (UM) nurse reviewer (registered nurse (RN) reviewer) are reviewed with a Health Net medical director or a specialty advisor. Physicians and members have the right to appeal all denied services. Care cannot be discontinued until the treating provider has been notified and has agreed to an appropriate discharge or transition of care plan.

Retrospective review is the review of the quality and necessity of medical services after care has been rendered. Retrospective professional review involves an evaluation of services that fall outside Health Net's established guidelines for coverage. These claims are reviewed by Health Net's professional review specialists (RN reviewers) and when the initial RN reviewer recommends that a claim be denied for lack of medical necessity, a Health Net medical director or a specialty advisor conducts a further review.