Utilization Management Program Components
Provider Type
- Physicians
- Participating Physician Groups (PPG)
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) and Molina Health Care in Los Angeles County for Medi-Cal. Following an evaluation of the operational capabilities of their UM program, Health Net’s decision to delegate UM is based on results of pre-delegation reviews and committee approval. Health Net does not delegate UM functions to individual participating providers. Health Net staff perform UM functions when operational functions are not delegated.
When Health Net delegates UM operational functions to PPGs, or Molina Health Care in Los Angeles County, PPGs (or Molina as applicable) 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 via ongoing monthly performance reporting, quarterly system validation reviews and annual reviews. Corrective actions are issued for below standard performance and when necessary, decisions regarding continued delegation will be reviewed by the Health Net Delegation Oversight Committee.
Health Net regional medical directors and clinical 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.