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.

Plan physicians and other 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.

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 physicians and other providers the programs, tools, connectivity, and information to make better health care decisions to:

Physicians and other 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, physicians and other 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. Physicians and other 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:

In addition, physicians and other 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:

If a Plan member meets any of these criteria, physicians and other 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, 7 days a week, 365 days a year in English and Spanish with translation services available for other languages.

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. Physicians and other 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:

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 physician or other 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. Physicians and other 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 physicians and other 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 physician or other provider needs to discuss the denial.

Physicians and other 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, physicians and other 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 physicians and other 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.

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 physicians and other providers to improve chronic disease care, patient satisfaction and efficiency.

The Plan is currently participating in 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, physicians and other providers can visit CQC.

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 physicians and other 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:

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, physicians and other 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.

Health Net features links to the hospital quality tool Cal Hospital Compare in multiple sections of our website. This source for hospital quality ratings and reports offers a broad range of information on individual facilities. Members can compare hospitals by rates of complications, patient experience ratings, maternity care performance, experience with specific types of procedures, and readmission rates. Cal Hospital Compare also features annual Honor Roll reports for hospitals that perform well on Maternity Care, Patient Safety, and/or Opioid Care based on priority indicators. This online tool is available to support informed decision-making when members are choosing a site for care. One section where Cal Hospital Compare links can be found is under the 'Find a Provider' section, then select hospital. The Cal Hospital Compare link is featured under each hospital profile page.

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 fourth 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:

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 27quality and safety measures. For more information, visit The Leapfrog Group.

Plan physicians and other 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 > Provider Manual > Benefits > Bariatric Surgery > Health Net Bariatric Surgery Performance Center or select Transplants > Health Net Transplant Performance Centers.

As appropriate, PCPs provide care for Plan members who have behavioral health diagnoses. The Plan also offers behavioral services. Physicians and other 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 physician 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 physicians 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.

Physicians and other 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).

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 the HEDIS Measures and Billing Codes page to view any of the following:

Additional resources are found under 'Microlearnings' in the Education, Training and Other Materials section of the Provider Library:

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:

Physicians and other 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 physicians and members with pharmacy coverage through the Plan. The Plan formularies and Medicare Part D Formulary serve as references for physicians 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 physicians receive information annually and when updates occur that include:

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.

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.

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 physicians to recommend safer alternatives.

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 physicians for proper pain assessment and treatment of Plan members.

The Plan’s current programming on opioid safety, specifically focusing on Morphine Milligram Equivalent (MME) thresholds, aims to ensure proper dosing and monitoring. For MME levels between 90 and 199, a soft edit is implemented at the point of sale, requiring the pharmacist to contact the prescribing physician to confirm the opioid dosing before entering an override code. For MME levels of 200 and above, a hard edit is enforced, requiring the physician to submit a prior authorization request before the prescription can be filled. This structured approach is designed to enhance patient safety and ensure the responsible use of opioids. Members may be referred to the Plan’s Clinical Pharmacy Team for high-dose opioids and dangerous drug combinations. A Plan pharmacist directly outreaches to members to educate and counsel on the risks of taking high-dose opioids, signs of opioid overdose and proper usage of Naloxone in case of overdose. The team verifies that members have naloxone in the home and will alert prescribers if not. Pharmacists educate members on medications for opioid use disorder (MOUD). Pharmacists can also refer members directly to the Plan’s Behavioral Health Call Center to screen for level of care and treatment and refer members to methadone clinics and local health departments, if needed. The Pharmacy Team also collaborates with members’ physicians to offer clinical recommendations and develop tapering plans, ensuring a comprehensive approach to opioid safety and management.

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 outreach to physicians and other providers of non-compliant Medicare members is conducted to facilitate BMD screening and/ or appropriate osteoporosis treatment. Proof of service documents are collected and uploaded into Cozeva as part of direct care gap closure. Furthermore, vendor administers in-home bone density testing alongside IHA visit for Medicare members having osteoporosis care gaps. Members that have recently suffered a fracture deal with impaired mobility and other barriers to treatment adherence such as costs, transportation issues and lack of convenience. The availability of BMD screening at member’s home provides appropriate screening and testing to close the gaps in osteoporosis care.

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 physicians and other providers through their annual wellness visit or online. Member responses to the assessment help guide physicians and other 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 physicians and other providers who meet their care needs.

The Plan notifies all applicable physicians and other 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 provider manual. Physicians and other 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 physicians and other providers, and all other health care professionals providing care to its members. Member rights and responsibilities statements are distributed to new physicians and other providers when they join the network and to existing physicians and other providers, if requested.

The member rights and responsibilities are available in the provider operations manual . The provider can request copies by contacting the Health Net Provider Services Center.

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:

Physicians and other providers may refer issues identified as QOC incidents to Health Net’s Customer Contact Center or Member Appeals and Grievances departments for appropriate resolution.

Physicians and other 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 physicians and other providers can only release PHI without authorization when:

Any other disclosure of a Plan member’s PHI must have a prior, written member authorization.

Plan physicians and other 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 physicians and other 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.

Medicare members, physicians and other providers have access to no cost interpreter services during call center business hours of operation for all medical points of contact. The member has the right to file a complaint or grievance if linguistic needs are not met.

Key points of contact include but are not limited to medical care settings such as patient encounters, interactions with pharmacists, diagnosticians, laboratory technicians. Key points of contact can also include non-medical care settings such as member services, appointment scheduling or orientations. Interpreter services will be provided without imposing an undue delay on the scheduling of the appointment. Member timely access to care will not be delayed due to any lack of interpreter services.

To obtain interpreter services, members, physicians and other 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 a video remote or 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 physicians and other 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 physician's and other provider’s responsibility to ensure completeness and accuracy of content, as well as the confidentiality of the health record. The Plan requires that the physician and provider adhere to the standards for maintaining member medical records and to safeguard the confidentiality of medical information.

Physicians and other providers are responsible for protecting the confidentiality interests of Plan members when responding to requests for information. All physicians and other 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 physician and other 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.