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Utilization Management Program Components

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)

Counties Covered

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

Utilization management (UM) is provided through a comprehensive, multi-level and flexible managed care delivery system. Health Net delegates the UM function to participating physician groups (PPGs) following an evaluation of the operational capabilities and performance of each group in the areas of administration, UM, member services, quality improvement (QI), and encounter data submission. Based on Health Net's evaluation, the PPG is assigned delegation or non-delegation status. Health Net does not delegate UM functions to individual participating providers.

These two performance categories define the interface between Health Net and the PPG and allow each PPG to be involved in the medical management process in a manner consistent with the PPG's current level of management sophistication and administrative resources. The categories are administered by Health Net and include different degrees of oversight and operational support.

When Health Net delegates UM operational functions to PPGs, PPGs are required to establish a formal UM program that describes how the delegated UM processes are performed and monitored. Health Net evaluates the effectiveness of the PPG program before UM is delegated and at least annually thereafter. Health Net staff perform UM functions when operational functions are not delegated.

Health Net regional medical directors and medical program managers are the principal liaisons between Health Net medical management and PPGs. Health Net UM and QI staff located in the corporate and regional offices support these directors and managers. They play an integral part in helping PPGs meet the expectations of Health Net and its members.

Last Updated: 08/06/2021