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Requirements for Notification of Utilization Management Decisions

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals

Health Net and its participating physician groups (PPGs) to which utilization management (UM) functions have been delegated are required to comply with standards established by the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA).

In accordance with CMS guidelines and federal regulations 42 CFR Section 422.620(d), prior to discharging a Medicare Advantage (MA) member from an inpatient level of care, the MA organization, and its delegated PPGs must obtain concurrence from the treating physician who is responsible for the member's inpatient care. 

Inpatient facility authorizations must be based on the treating physician's orders and plan of care. MA inpatient denials cannot be issued by PPGs or Health Net unless there is concurrence from the Health Net MA member's treating physician. However, the inpatient hospitalization episode of care, as directed by the treating physician, is subject to post-claim payment review and recoupment, if deemed appropriate based on CMS criteria, including federal laws, rules, regulations, and CMS manual guidelines. Health Net is engaging a vendor to perform such post-claim payment review, which may involve requests to PPGs for medical records in order to determine appropriate actions based on CMS criteria for medical necessity.

Health Net oversees, and is ultimately responsible to CMS for, any functions and responsibilities described in MA regulations. In accordance with federal regulation 42 CFR Section 422.504 (i)(4)(v), Health Net and its delegated PPGs must comply with all applicable Medicare laws, regulations and CMS instructions.

Last Updated: 10/30/2019