Quality Management Program and Resources
Wellcare By Health Net’s quality management program continuously monitors and evaluates the quality, appropriateness and outcome of care and services delivered to our members. It includes the development and implementation of standards for clinical care and service, measurement of compliance to standards, and the implementation of actions to improve performance.
Below is an overview of the components of the multifaceted quality management program. It includes quality improvement (QI) processes and instructions on how to get more information from the Health Net provider website.
Open clinical dialogue
Plan practitioners and providers are encouraged to talk freely with members about their medical conditions, treatment options and medications, regardless of limits to coverage.
The Plan unifies programs, from wellness to complex care, reflecting our commitment to a whole-person strategy. Members who qualify have access to wellness programs for obesity prevention, smoking cessation, pregnancy support, and chronic conditions management.
Health and wellness program
The Plan offers a health management solution to improve members’ health and quality of life. Through personalized interventions and contemporary behavior change methodologies, the Plan's experienced staff can help members at risk and diagnosed with chronic health conditions to better manage their conditions through education, empowerment and support. The Plan includes a suite of programs and support encompassing health and wellness, integrated care management, case management, and women’s and children’s health.
The Plan offers many tools and programs to help members adopt and maintain healthy lifestyles, such as:
- RealAge® test (health assessment) – An online interactive tool that helps members identify health risks based on current lifestyle behaviors and family history. Members are provided a summary of their health results that can be printed and shared with their physicians.
- Health profile – An online secure database where members can track important medical history, including health conditions, immunizations, medications, tests, and procedures. Information from the RealAge test automatically becomes part of their personal profile. .
- Online wellness resources – Offers a flexible way to improve health and wellness – on the member’s own terms. The content library has a variety of physical, emotional, social, financial health, and clinical materials. This consists of numerous articles and videos that relate to healthy weight, improving your diet, stress management, tobacco cessation, and more. Examples of some of our online wellness resources include health articles, trackers, health videos, and health challenges.
- Health coaching – One-to-one telephonic health coaching provides extra help individuals need; online health coaching and resources provide additional support to members. A personal health coach helps with short- and long-term goal setting and achievement for lasting results. The program includes trackers and easy tools to use in the behavior change process. Personalized health coaching is available for weight loss, healthy eating, stress management, and exercise. Additional program and enrollment information is available online at Health Net Sharecare.
- RealAge Program – The RealAge Program is Sharecare’s comprehensive healthy behavior program targeting the four highest lifestyle risks — stress, sleep, nutrition, and activity. The program is personalized to members based on risk level for each lifestyle category and personal interest. It’s fully integrated with other features of the Sharecare platform, such as trackers, to drive sustained engagement and promote behavior change that can lead to a lower RealAge. Members will be offered a weekly goal based on their RealAge test responses. The goal is recommended based on their current behavior. Members will select from a list of barrier statements that provide insight into their current habits and lifestyle. Finally, members will be presented with a list of small behaviors (action steps). These steps can be adopted as part of their daily routine to directly overcome the barriers selected in the previous question. Once members select two or more action steps and complete the assessment, they have completed the program set up and enrollment is complete.
- Eat Right Now Program – Eat Right Now is a new evidence-based program that combines neuroscience and mindfulness tools to help members identify eating triggers and ride out cravings to change their eating patterns for good. With help from videos and exercises, members will learn to listen to their body’s hunger signals so they can differentiate between real hunger and emotional cravings. This progressive 28-day program lets members reshape how they eat in about 10 minutes a day. Through video, audio and animated lessons, clinically validated exercises and on-demand tools, members lean how to identify, work with and eliminate their eating triggers.
- Unwinding by Sharecare – Unwinding is a mindfulness program designed to manage stress and build resilience in the workplace and at home, while also improving sleep, mental health and quality of life. Developed by psychiatrist and neuroscientist Dr. Jud Brewer, MD, PhD, and the Behavioral Health team at Sharecare, Unwinding offers on-demand stress reduction tools to help you deal with stress throughout the day. Through the app, you can improve sleep, access breathing exercises, follow guided meditations, watch high-end relaxation video content, attend live virtual events, and more.
- Smoking cessation program – Coaching support is available 24/7 for up to a year during their flexible quit approach. A member initiates through the Teladoc smartphone app, or visiting TeladocTM, or referred into the program by a provider during a general medical visit. Ways to request a consult include the smartphone app, website, or dialing 800-TELADOC (800-835-2362 TTY: 711).
- Healthy discounts – Plan members have access to exclusive discounts on eye care, vitamins, herbs and supplements, health clubs, and other health-related products and services, including discounts for hearing care and WW® (Weight Watchers).
- Health challenges – Online challenges to help individuals achieve small changes related to healthy eating, exercise, stress management, and weight loss. The health challenges offer focused behavior change strategies and record keeping to help participants stay on track for success.
- Tools, such as decision aids and symptom checker, to help members understand their health plan options so that they can choose what is best for them.
Chronic conditions management
The Integrated Care Management program addresses the physical, behavioral and psychosocial needs of the member as part of the Plan's Population Health Management. The program supports members, families and caregivers by assisting members in achieving optimum health, functional capability and quality of life through improved management of their disease or condition.
Management of chronic conditions (diabetes, asthma and chronic obstructive pulmonary disease (COPD)) and cardiac conditions (heart failure, coronary artery disease and hypertension) is incorporated into the Integrated Care Management program.
The Plan offers participants and their providers the programs, tools, connectivity, and information to make better health care decisions to:
- Slow the progression of the disease and the development of complications through proven program interventions.
- Change behaviors and improve lifestyle choices by using demonstrated behavior change methodologies.
- Improve compliance with guidelines and the member’s plan of care.
- Manage medications and enhance symptom control.
- Educate members regarding recommended preventive screenings and tests according to national clinical guidelines.
- Encourage the correct use of medications to prevent medication errors.
Providers and members may contact their designated care manager for additional assistance with chronic conditions management.
The Plan identifies potential gaps in care through claims, encounters and pharmacy data as well as all available supplemental data sources from provider groups. This includes laboratory data, electronic medical record, registry data, and health information exchanges. The Plan posts care gap reports bi-monthly on Cozeva®, and monthly reports on the provider portal.
Cozeva allows for bi-directional data transfers between the Plan and medical groups via a web-based platform. It provides actionable information on care-gap opportunities, as well as insights into provider performance on key quality measures compared to national benchmarks and the Plan network.
For members, the care gap data are also used to engage with members. Care reminder messages are sent when potential gaps in care are identified through claims, laboratory data and other sources. These reminders aim to help specific individuals take action and to align with industry-recognized Healthcare Effectiveness Data and Information Set (HEDIS®) measures to improve preventive health, chronic condition management and more.
Powered by findhelp, Health Net Community Connect offers the largest online search and referral platform. There are 10 topics to choose from, such as food, housing and transportation. Then select a subtopic which will contain a list of services based on the ZIP Code entered. The results can be viewed in over 100 languages. To use the tool, go to Health Net Community Connect, take the Social Needs Assessment, enter a ZIP Code and click on Search.
The Plan's Integrated Care Management (ICM) program provides whole person-centered care that addresses the member’s medical, mental and psychosocial needs. The ICM program targets the most complex cases, often with life-limiting diagnoses, and assist members who have critical barriers to their care. Trained Registered Nurses and Licensed Clinical Social Workers provide case management services to Plan members, their families and caregivers as needed. These members may have multiple comorbid conditions and need assistance in planning, managing and executing their care.
The Plan conducts utilization surveillance and uses predictive modeling tools to identify appropriate members for this program; however, providers may also become aware of a severely ill Plan member not currently enrolled in this program who may benefit from integrated case management services. Providers should use the criteria below when considering whether to refer a member to the integrated case management program.
It is appropriate to refer Plan members with the following complex concerns to this program for evaluation:
- Moderate to late-stage cancer, neurological, circulatory, endocrine, respiratory conditions, and uncontrolled pain/uncontrolled symptomology.
- Multiple care providers who may not be communicating with each other, which increases the risk of an acute event, such as hospital readmission.
- Advanced chronic diseases with multiple hospitalizations (greater than two in the last six months).
- Experiencing significant symptoms and side effects that could lead to an emergency room visit or hospitalization.
- Problematic or unstable comorbidities.
- Rare conditions requiring more extensive education, care coordination and support.
- Member seeking alternative therapeutic options, using out-of-network facilities and providers.
- Clinical trials.
- Active terminal care issues.
- High utilization of expensive resources, including multiple admissions or frequent emergency room visits.
- Complex support and caregiver needs.
- Acute uncontrolled symptoms of disease process or treatment.
- High degree of coordination, integration, referrals, and planning needed.
- Social determinant issues which may include:
- No support system or inadequate support system that is unable to cope without intervention.
- Caregiver burnout.
- Unsafe environment.
- Significant financial difficulties.
In addition, providers should consider the questions below to determine whether the member has one or more of the following issues that cannot be managed by the provider’s office or treating specialists:
- Does the member have a terminal diagnosis or prognosis and struggle with whether to proceed with aggressive or palliative treatment?
- Is the member experiencing significant problems due to disease-related pain and symptom control, such as fatigue, anxiety, nausea, constipation, dyspnea, or depression?
- Does the member live in an unsafe environment?
- Does the member have significant financial issues?
- Does the member have multiple providers of care who may not be communicating, which creates an ongoing risk for an acute event, such as readmission?
- Has the member developed severe, complicated comorbidities?
- Does the member have an inadequate support system or is the primary caregiver suffering from burnout?
- Is the member frequently using the emergency room to obtain their care?
If a Plan member meets any of these criteria, providers may contact the Care Management Department. Members who want to self-refer to this program may call the toll-free Customer Contact Center number on the back of their Plan identification (ID) cards. The Customer Contact Center representative contacts the Case Management Department with the member’s information for appropriate outreach. Contacting the Case Management Department does not automatically qualify the member for the integrated case management program.
The Nurse Advice Line provides appropriate and timely triage for health-related problems through registered nurses (RNs) utilizing industry-approve guidelines and protocols. Using nationally recognized algorithms and world-class clinical triage guidelines, nurse advice line RNs identify member needs and ensure they are directed to the appropriate level of care for the situation – whether it is providing self-care guidance, or recommending a visit to urgent care or the ER. The service is offered 24 hours a day, seven days a week, 365 days a year in English and Spanish with translation services available for other languages.
Clinical practice guidelines
The Plan's evidence-based clinical practice guidelines are updated at least every other year and when new scientific evidence or national standards are published. Centene’s Corporate Clinical Policy Committee and/or the Plan's Medical Advisory Council (MAC) adopt the clinical practice guidelines and tools, which are available on the Health Net provider website. Providers who do not have access to the Internet may contact the Health Net Provider Services Center to request printed copies of these guidelines.
Guideline sources include, but are not limited to, the following:
- Chronic conditions management – Clinical guidelines are available for providers to quickly reference information about a number of chronic conditions, which include asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes, and heart failure. Sources are found within the guidelines.
- Behavioral health – Clinical guidelines are available for such disorders as attention deficit hyperactivity disorder (ADHD) and substance use disorder.
Preventive health guidelines
The Plan's preventive health guidelines are standards of care developed to encourage the appropriate preventive services to members, according to their age, gender and risk status. These services include screening tests, immunizations and physical examinations. The Plan bases these guidelines on recommendations from evidence-based sources, such as the United States Preventive Services Task Force (USPSTF), Advisory Committee for Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC), American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS), and American Academy of Family Physicians (AAFP). These guidelines do not address the specific diagnostic testing or medical care that may be necessary as indicated by the member’s medical history and physical examination. As always, the judgment of the treating provider is the final determinant of member care.
Centene’s Clinical Policy Committee and the Plan's MAC review preventive health guidelines periodically. The guidelines are available on the Health Net provider website. Providers who do not have access to the Internet may contact the Health Net Provider Services Center to request printed copies of these guidelines.
The Plan uses utilization management (UM) decision-making criteria that are objective and based on medical evidence to determine medical necessity, including InterQual®, Hayes Medical Technology Directory, Medicare coverage determinations, and Centene clinical policies and Plan medical policies.
Centene and Plan medical policies are available to providers on the Health Net provider website.
When a medical necessity decision results in a denial, the denial letter contains an explanation of the denial, the criteria used to make the decision and appeal rights. The letter also includes the contact name and phone number of the Plan medical director if the requesting provider needs to discuss the denial.
Practitioners and providers participating with a Plan delegated partner may also contact the delegated partner’s UM department for the UM criteria. Plan UM staff are available by contacting the Health Net Provider Services Center. The delegated partner UM staff can be contacted through the delegated partner.
UM decisions are based only on appropriateness of care, service and existence of coverage. The Plan does not reward practitioners, providers or other individuals for issuing denials of coverage for health care or services. There are no financial incentives for UM decision-makers to encourage decisions that result in underutilization.
The Quality Improvement Department utilizes several specific quality initiatives to help improve member health outcomes, focusing on engaging with providers and direct care gap closure. Members may receive general or targeted outreach through various modes providing them with important educational information or reminders to take action when necessary. The focus of these initiatives may include preventive health screenings, influenza and vaccines, chronic disease management, and medication management. Outreach may be conducted by qualified vendors contracting with
The Plan also collaborates with the California Quality Collaborative (CQC) to facilitate the sharing of ideas, best practices and resources. Various programs are available to providers to improve chronic disease care, patient satisfaction and efficiency.
The Plan is currently participating on CQC’s Behavioral Health Integration Initiative from 2022 through 2027, funded by Centene Corporation and California Health Care Foundation. This initiative will accelerate integration efforts by small and independent primary care practices throughout the state. The initiative aims to improve screening, diagnosis and treatment of patients’ mild-to-moderate behavioral health needs, like depression, anxiety and substance use disorder.
For a listing of educational programs and patient satisfaction and condition management resources, providers can visit CQC.
Medicare Star Ratings
Improving quality of care is of primary importance for the Centers for Medicare & Medicaid Services (CMS) and one method it uses to monitor plans to ensure they meet Medicare’s quality standards is the Medicare Star Ratings. This system is also used by CMS to tie improved quality of care for MA beneficiaries to quality bonuses. The ratings provide a tool for Medicare members to compare the quality of care and customer service offered by MA health and pharmacy plans. It is important that providers participate in and promote QI initiatives to improve the quality of care provided to MA members. Provider activities to help meet the goals of these QI initiatives include:
- Ensuring patients are up to date with all preventive health screenings.
- Developing or using registries to improve chronic disease management.
- Identifying patients with gaps in care and providing prompt follow up.
- Conducting comprehensive annual exams to monitor medications, document care needs, review care plans, determine functional status, and identify social and physical needs (including pain status), and barriers they may have to routinely taking their medications.
- Coding claims and encounters accurately for the best data capture.
- Distributing educational materials to patients to help them understand and recall discussions, and improve compliance with their treatment plans.
Quality measures and suveys
The Plan measures quality of care and services provided to members in a number of ways, including HEDIS for performance measures for care and service, Consumer Assessment of Healthcare Providers and Systems (CAHPS®) for annual assessments of member satisfaction and the Health Outcomes Survey (HOS®) for Medicare members.
The information gathered from members, practitioners and providers enables the Plan to address opportunities for improvement and are the basis for the implementation of various QI initiatives. Plan performance results for many of these efforts are available online through the provider portal or by mail on request.
Quality and safetly reporting
The Plan offers WebMD’s Hospital Advisor tool, which provides hospital-specific performance information by diagnosis or procedure, and features metrics including volume, cost, mortality, and complication rates. Data are based on a variety of sources, such as state figures reporting from The Leapfrog Group, CMS hospital quality indicators, and patient satisfaction information. This online tool is available to members and providers to support informed decision-making when choosing a site for care. Go to the ‘Find a Provider’ section and select hospital. The Hospital Advisor tool is available under each hospital profile page through the end of 2023. Hospital quality information will continue to be available from Cal Hospital Compare starting in 2024.
The Leapfrog Group
The Leapfrog Group is an organization founded to promote patient safety and improve quality of care. Since 2014, the Plan has been a Leapfrog Partner and actively works with Leapfrog and its partners to improve the safety and quality of care. Health Net is serving as co-chair of Leapfrog’s Partners Advisory Committee for the third year and participates in its Data Users Group.
The Plan's work as a Leapfrog Partner includes promoting participation in the Leapfrog hospital survey, which offers consumers key information about a facility’s quality and safety performance with respect to established patient safety practices and progress toward national quality standards. Examples of hospital survey measures include:
- Computerized physician order entry (CPOE).
- Intensive care unit (ICU) physician staffing.
- Evidence-based hospital referral.
- Safe practices score based on National Quality Forum (NQF) standards.
Participation in Leapfrog’s surveys offer hospitals the ability to assess their strengths and weaknesses in areas such as hospital-acquired condition scores and evidence-based care to address common acute conditions.
In addition to making these survey findings publicly available, Leapfrog publishes a Hospital Safety Grade. The composite score assigns individual hospitals a letter grade to indicate hospital performance on patient safety according to an analysis of up to 30 quality and safety measures. For more information, visit The Leapfrog Group.
Plan providers must utilize contracted transplant and bariatric performance centers for all members qualifying for these procedures to promote the best clinical outcomes and coordination of care. These performance centers and their participating surgeons have been selected based on adherence to national guidelines and accredited requirements and have demonstrated an ongoing commitment to improving surgical performance and patient outcomes. The performance centers are also expected to coordinate a seamless transition of care by sharing information and keeping PCPs informed of their patients’ status. Lists of transplant and bariatric performance centers are available in the Provider Library > Operations Manual > Benefits > Bariatric Surgery or Transplants.
As appropriate, PCPs provide care for Plan members who have behavioral health diagnoses. The Plan also offers behavioral services. Practitioners and providers may refer members for behavioral health services or members can self-refer by calling the phone number on their health plan ID cards.
For routine behavioral health service requests, the Plan notes the member’s needs, geographic area, benefit plan, and scheduling requirements to identify a practitioner or program that meets the clinical needs of the member. Member preferences, such as gender and cultural experience, are considered whenever possible. The Plan's standards make services available within six hours for non-life-threatening emergencies, within 48 hours for urgent situations, within 10 business days for routine services with a non-physician mental health provider, and 15 business days with a psychiatrist.
PCPs and their office staff may contact Member Services and speak with a licensed care manager (CM). Patients must sign an Authorization for Disclosure form before the PCP or office staff speaks to the CM. For physicians who need help finding appropriate behavioral health care for their members, Member Services representatives can answer questions about the Plan's network of practitioners and programs, the referral process, member eligibility and benefits.
Coordination of care is fundamental to the member’s well-being. PCP offices that receive information from other medical or behavioral health specialists are encouraged to document the information in the member’s medical record and review relevant information with the member at his or her next primary care visit.
Screening for depression
Practitioners and providers are encouraged to screen members for depression and other behavioral health conditions. Various brief screening instruments are available, such as the Patient Health Questionnaire (PHQ-9) from the U.S. Preventive Services Task Force. There is no cost to users and it is available in English and over 30 other languages. Newly enrolled Medicare members are screened for depression through a health risk assessment (HRA).
The Plan offers medication reminders and educational messages for adult members identified with depression. Members who are newly prescribed with an antidepressant medication receive automated IVR calls. The calls also offer a phone number to call a pharmacist if there are any medication-related questions. The call also offers a live transfer to the Plan, if members would like to talk to a psychiatrist, therapist or other behavioral health provider about their medicine.
Most Plan members appropriately seek depression treatment from their PCPs, which is why The Plan provides physicians and PPGs with the following tip sheets to manage and coordinate care for their patients with depression. Go to Health Net website and select Provider Tip Sheets, then select:
- Antidepressant Medication Management – AMM Tip Sheet.
- Behavioral Health (BH) Information Exchange to Help Improve Outcomes – BH Information Exchange.
- Depression Screening and Follow-Up – CDF, DSF Tip Sheet.
Alcohol and substance use
To help improve the diagnosis, treatment and follow-up care of alcohol and other drug (AOD) use, the Plan has included information about signs, symptoms and PCP management in the following tip sheets. Go to HEDIS Measures and Billing Codes page to view any of the following:
- Alcohol and Other Drug Treatment – IET Tip Sheet.
- Behavioral Health (BH) Information Exchange to Help Improve Outcomes – BH Information Exchange.
- Follow-up after an Emergency Department Visit for Mental Illness (FUM)/Follow-up after an Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence
(FUA) – FUM/FUA Tip Sheet.
Providers have access to the Member Services line by dialing the number on the back of the member’s ID card or by dialing 844-966-0298 for help finding appropriate care for members, information about the referral process, member eligibility, and benefits.
The Plan and Centene Corporate Pharmacy and Therapeutics (P&T) Committees and the Envolve Pharmacy Solutions Strategy Development Committee manage the Plan formularies, Medicare Part D Formulary and Health Net Drug Usage Guidelines. These documents are available to participating providers and members with pharmacy coverage through the Plan. The Plan formularies and Medicare Part D Formulary serve as references for providers to use when prescribing pharmaceutical products for health plan members with pharmacy coverage. The Plan formularies and Medicare Part D Formulary are available on the Health Net provider website. Then select Drug Information for Commercial Plans or for Medicare Plans under Drug Lists. The Plan P&T Committee consists of actively practicing physicians and pharmacists. The committee reviews medications based on clinical efficacy, safety, side effects, cost-effectiveness, quality outcomes, and comparisons to existing products.
The committee also develops protocols for medications requiring prior authorization. Considerations include benefit plans and exclusions, step-care protocols, quantity or duration limits, and potential for misuse. Other considerations are potential usage indications that do not meet U.S. Food and Drug Administration (FDA) criteria, experimental or off-label use, and required level of laboratory or safety monitoring. The medication list and usage guidelines are reviewed and updated quarterly by the P&T Committee.
Prescribing practitioners receive information annually and when updates occur that include:
- A list of pharmaceuticals with restrictions and preferences.
- How to use the pharmaceutical management procedures.
- An explanation of limits or quotas.
- How prescribing practitioners must provide information to support an exception request.
- The process for generic substitution, therapeutic interchange and step-therapy protocols.
The Envolve Pharmacy Solutions Strategy Development Committee may recommend cost-based tier placement in the formularies for medications determined to be clinically equivalent by the P&T Committee.
Pharmacy clinical and safety initiatives
The Plan's pharmacy clinical and safety initiatives focus on the following topics: use of potentially high-risk medications in the elderly; appropriate narcotic/acetaminophen utilization; antibiotics; osteoporosis; medication therapy management (MTM) program; and medication adherence.
Use of Potentially High-Risk Medications in the Elderly Initiative
The primary objective of the Use of Potentially High-Risk Medications in the Elderly Initiative is to improve the quality of care in the elderly population through the promotion of appropriate prescribing. Medication safety is also a HEDIS and NCQA accreditation measure for Medicare members.
The Plan has developed specific prior authorization criteria delineating potentially harmful use of medications in the elderly. The criteria have been derived from recent medical studies and publications, including the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults list on adverse medication events in elderly members. The information indicates specific medications that should be avoided and suggests alternatives. Community pharmacists may also contact providers to recommend safer alternatives.
Appropriate Opioid Utilization Initiative
The Appropriate Opioid Utilization Initiative’s objectives are to reduce opioid overutilization, promote appropriate opioid use by members, enhance coordination of care between prescribers, and decrease the use of opioids after filling a prescription for opioid dependence. In addition, the program offers strategies and tools to providers for proper pain assessment and treatment of Plan members.
The Plan sends targeted providers a biannual mailing, including a letter, medication reviews of members identified as having a high use of narcotic medications (greater or equal to 90 MME per day) and notifies all prescribers.
The Plan's pharmacy benefit manager (PBM) has implemented an opioid overutilization program to manage narcotic utilization for MA Part D prescription drug (MA-PD) members. The program includes a pharmacist review of opiate prescriptions, notifications to members and providers, clinical discussions with members and providers, documented interventions in a central system, and point of service edits to restrict use if needed. Information about appropriate narcotic prescribing is on the Health Net provider website.
The primary objective of the Osteoporosis Initiative is to improve the quality of care for post-menopausal women with osteoporotic fractures. Members who have not had a bone mineral density (BMD) test or an appropriate medication for osteoporosis treatment after an osteoporotic fracture are identified for intervention.
Targeted Medicare members receive educational materials in the mail. Members may also receive calls from a vendor who offers in-home bone mineral density tests. Targeted providers are faxed an Osteoporosis Fracture Patient Alert with a claims history of their patients. The program is a bimonthly intervention to reach high-risk members in a timely manner.
Medication therapy management program
MA members with a prescription medication benefit are eligible for the MTM program if they have eight or more chronic medications; three or more of the following conditions: COPD, depression, osteoporosis, diabetes, or hyperlipidemia; and are likely to incur an annual medication cost of $4,376, as specified by CMS. All Special Needs Plan (SNP) members are also enrolled in the MTM program, regardless of the criteria listed above. In this program, Plan pharmacists review medication claims to reduce therapeutic duplications, find opportunities to reduce costs, fill therapeutic care gaps, improve medication adherence, inform members of medication interactions, and provide education on medication-age contraindications.
The Plan sends targeted members a letter with recommendations and a phone number to connect them to a health plan pharmacist and receive a comprehensive medication review, including a review of over-the-counter or herbal products. The Plan also sends physicians a fax notifying them of the same issues so they can coordinate the member’s care. For SNP members, the Plan sends copies of the interventions to PCPs and case managers.
The Plan's PBM calls MA-PD members taking oral diabetes medications, statins and renin-angiotensin system inhibitors to evaluate and help them overcome barriers to medication adherence. Members identified as non-adherent receive an IVR call with an option to speak with a pharmacist to address barriers and an offer for pillboxes, if useful. The PBM sends follow-up letters to members who could not be reached on the phone. All members receive a flyer with written information for future reference.
The Plan encourages completing a personal wellness assessment or HRA for new MA members within 90 days of enrollment and annually thereafter. The assessment can be completed with their primary care providers through their annual wellness visit or online. Member responses to the assessment help guide providers on MA member’s medical or behavioral health concerns for additional care coordination needs.
The Plan strives to ensure compliance with all applicable state, federal, regulatory, and accreditation requirements to provide members with timely access to care. The Plan regularly monitors the network and evaluates whether members have enough access to practitioners and providers who meet their care needs.
The Plan notifies all applicable providers about the Plan's established appointment access standards, network adequacy requirements, and access and availability monitoring processes. The standards include, but are not limited to, appointment waiting times for routine, urgent and preventive care; requirements for after-hours access to care; and other requirements and guidelines for access to medical care as mandated by the applicable regulatory body for the line of business.
The complete set of access standards and revised after-hours script templates are available in the Access to Care and Availability Standard section of the operations manual. Providers who do not have access to the Internet may contact the Health Net Provider Services Center to request printed copies of these standards and after-hours script templates.
The Plan is committed to treating members in a manner that respects their rights, recognizes their specific needs and maintains a mutually respectful relationship. In order to communicate this commitment, the Plan has adopted member rights and responsibilities. These rights and responsibilities apply to members’ relationships with the Plan, its practitioners and providers, and all other health care professionals providing care to its members. Member rights and responsibilities statements are distributed to new practitioners when they join the network and to existing practitioners, if requested.
In compliance with regulatory requirements and to ensure members receive the highest quality of care (QOC), the plan monitors and evaluates potential quality of care issues involving health plan members through the Plan quality management program. QOC incidents may include, but are not limited to, the following:
- Practitioner/provider denies necessary service(s) to member.
- Concerns that care provided did not meet professionally recognized standards of healthcare.
- Member exposed to serious harm.
- Appropriate care provided but member experienced adverse outcomes.
- Neglect or physical, mental, or psychological abuse.
- Testing/assessment insufficient, inadequate, or omitted.
- Concerns about prescriber, medications, or medication management.
Potential Quality Incident Referral Form
Providers can complete the Potential Quality Incident Referral Form and submit it to the Grievance Department, preferably within one business day of the incident. The indicators on the form refer to an event or trigger. Use the broad general category lists to identify the potential quality of care issue, or use the Other category to describe the incident. Additional completion instructions are provided on the form.
A member or a member representative who believes that a determination or application of coverage is incorrect has the right to file an appeal. The Plan responds to Medicare standard appeals within 30 calendar days. A 72-hour appeal resolution is available if waiting could seriously harm the member’s health.
The Plan does not delegate member grievances or appeals. All grievances and appeals must be forwarded within one business day to the Health Net Appeals and Grievances Department.
Federal regulations stipulate that special appeals procedures must be followed for MA members. MA members may first appeal to the health plan. If the denial decision is upheld, or partially upheld, the case is forwarded to the independent review entity. The MA appeals procedure does not include binding arbitration. MA members have a right to appeal any decision about payment for, or failure to arrange or continue to arrange for, what the member believes are covered services (including non-Medicare-covered benefits) under the Health Net MA plan. More information about the MA member appeals process is available in the Health Net Provider Library under Provider Manual.
Plan members’ protected health information (PHI), whether it is written, oral or electronic, is protected at all times and in all settings. Plan practitioners and providers can only release PHI without authorization when:
- Needed for payment.
- Necessary for treatment or coordination of care.
- Used for health care operations (including, but not limited to, HEDIS reporting, appeals and grievances, UM, QI, and disease or care management programs).
- Where permitted or required by law.
Any other disclosure of a Plan member’s PHI must have a prior, written member authorization.
Plan practitioners and providers must ensure that only authorized people with a need to know have access to a member’s PHI. The Plan requires PPGs to obtain Health Insurance Portability and Accountability Act (HIPAA) Business Associate agreements from people or organizations with which the PPG participates to provide clinical and administrative services to members.
Special authorization is required for uses and disclosures involving sensitive conditions, such as psychotherapy notes, AIDS or substance abuse disorder (SUD). To release a member’s PHI regarding sensitive conditions, Health Net practitioners and providers must obtain prior written authorization from the member (or authorized representative), which states the information specific to the sensitive condition that may be disclosed.
Interpreter services are available 24/7 at no cost to plan members and providers without unreasonable delay at all medical points of contact. The member has the right to file a complaint or grievance if linguistic needs are not met.
- Providers may not request or require an individual with limited English proficiency (LEP) to provide their own interpreter.
- Providers may not rely on staff other than qualified bilingual/multilingual staff to communicate directly with individuals with LEP.
- Providers may not rely on an adult or minor child accompanying an individual with LEP to interpret or facilitate communication.
- A minor child or an adult accompanying the patient may be used as an interpreter in an emergency involving an imminent threat to the safety or welfare of the individual or the public where there is no qualified interpreter for the individual with LEP immediately available.
- An accompanying adult may be used to interpret or facilitate communication when the individual with LEP specifically requests that the accompanying adult interpret, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.
- Providers are encouraged to document in the member’s medical record the circumstances that resulted in the use of a minor or accompanying adult as an interpreter.
To obtain interpreter services, members and providers can contact Health Net Member Services at the phone number located on the member’s ID card. Request in-person interpreters, including sign language interpreters, a minimum of five business days before the appointment during business hours.
Please allow for video remote or a phone interpreter if that is the only option available for the language, date and time of the appointment.
The Plan has established standards for the administration of medical records that ensure medical records conform to good professional medical practice, support health management and permit effective member care. A good medical record management system provides support to clinical practitioners and providers in the form of efficient data retrieval. It also makes data available for statistical and quality-of-care analyses.
The medical record serves as a detailed analysis of the member’s history, a means of communication to assist the multidisciplinary health care team in providing quality medical care, a resource for statistical analysis, and a potential source of defense support information in a lawsuit. It is the practitioner’s and provider’s responsibility to ensure completeness and accuracy of content, as well as the confidentiality of the health record. The Plan requires that the practitioner and provider adhere to the standards for maintaining member medical records and to safeguard the confidentiality of medical information.
Practitioners and providers are responsible for protecting the confidentiality interests of Plan members when responding to requests for information. All practitioners and providers must have policies and procedures that address confidentiality and the consequences of improper disclosures of member PHI. Refer to the Medical Records topic in the provider operations manual to review specific levels of medical record security that must be addressed by practitioner and provider policies and procedures governing the confidentiality of medical records and the release of member PHI.
The Plan monitors medical record documentation compliance and implements appropriate interventions to improve medical record-keeping. Medical record guidelines are available through the original website at provider.healthnet.com or upon request by contacting the Health Net Provider Services Center.