20-427 Help Your Patients Achieve Better Health Outcomes

Date: 08/05/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

Summary Update

Use quality management programs and resources to support the care you give

Health Net’s quality management program is designed to monitor and assess the appropriateness of health and administrative services on a regular basis. A complete overview of the quality management program components is described in provider update 20-427, Help Your Patients Achieve Better Health Outcomes, available in the Provider Library using the instructions below.

Quality improvement program scope

The program includes the standards for clinical care and services, the measurements of adhering to the standards, and the implementation of actions to improve performance.

The scope of the program includes:

• Impact of COVID-19.
• Wellness and chronic conditions management.
• Initial health and health risk assessments.
• Community health education programs and services.
• Clinical practice and preventive health guidelines.
• Notification of access standards.
• Medical record documentation standards.
• Medical records and facility site review.
• Utilization management process.
• Quality improvement initiatives, measures and surveys.
• Quality and safety reporting.
• Pharmaceutical management.
• Behavioral health services.
• Member rights and responsibilities.
• Member appeals 
• Privacy and confidentiality.
• Interpreter services.

Access provider update 20-427 in the Provider Library

Use either option below to access the library:

Option 1 – Log in to the provider website

1    Log in to provider.healthnet.com.

2    From the home page, scroll to the bottom and select the Provider Library tile.

3    Access provider update 20-427 under Updates and Letters > 2020 Updates and Letters.

Option 2 – Go directly to the Provider Library

1    Go to providerlibrary.healthnetcalifornia.com.

2    Access provider update 20-427 under Updates and Letters > 2020 Updates and Letters.

If you do not have access to the internet, you may request a print copy of update 20-427. Contact the Health Net Provider Communications Department by email.

Go online for more information

More information about all the programs listed on the page 1 is available on the Health Net provider website.

Also online is the Quality Improvement Corner. Here you can view Health Net’s quality outcomes and progress toward goals. You can also access tools and materials to help you give the care that members expect. Go to provider.healthnet.com > Working with Health Net > Quality.

Additional information

Providers are encouraged to access Health Net’s provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by county within 60 days at:

Line of Business	Telephone Number	Email Address
Cal MediConnect – Los Angeles County	1-855-464-3571	provider_services@healthnet.com
Cal MediConnect – San Diego County	1-855-464-3572

_________________________________________________________________________________________________

Complete Update

Use quality management programs and resources to support the care you give

This update provides the components of the Health Net* multifaceted quality
Cal MediConnect Plan (Medicare-Medicaid Plan) management program. It includes quality improvement (QI) processes and instructions on how to get more information from the Health Net provider website at provider.healthnet.com.

Quality improvement program scope

The Health Net QI program monitors and evaluates the appropriateness of health and administrative services on a regular basis. It includes the development and implementation of standards for clinical care and service, the measurement of adherence to the standards, and the implementation of actions to improve performance.

The scope of the program includes:

• Impact of COVID-19
• Wellness and chronic conditions management.
• Initial health and health risk assessments.
• Community health education programs and services.
• Clinical practice and preventive health guidelines.
• Notification of access standards.
• Medical record documentation standards.
• Medical records and facility site review.
• Utilization management process.
• Quality improvement initiatives, measures and surveys.
• Quality and safety reporting.
• Pharmaceutical management.
• Behavioral health services.
• Member rights and responsibilities.
• Member appeals 
• Privacy and confidentiality.
• Interpreter services.

Impact of COVID-19 on regulations and requirement

The following table lists impacts to the Quality Management Program due to COVID-19. Providers must comply with all applicable contract requirements, state and federal regulations and guidance, including All Plan Letters (APLs) and Policy Letters from the Department of Health Care Services (DHCS).

COVID-19 impacts	Description
Healthcare Effectiveness Data and Information Set (HEDIS®) measurement year (MY) 2019/reporting year (RY) 2020	National Committee for Quality Assurance (NCQA) will not be requiring Medicare Advantage plans to submit their data for accreditation purposes. The Centers for Medicare & Medicaid Services (CMS) will use last year’s scores and ratings for 2020 Star Ratings for scoring in 2021 Star Ratings.
Consumer Assessment of Healthcare Providers & Systems (CAHPS®) Survey	NCQA will not be requiring Medicare Advantage plans to submit their data for accreditation purposes. Quality Compass 2020 Medicare products will not be reported or released.
Health outcomes survey (HOS)	The HOS has been postponed to late summer 2020, per guidance from CMS.
Initial health assessment (IHA) and Staying Healthy Assessment (SHA)	Per DHCS All Plan Letter 20-0041, contractual requirements of completing the initial health assessment for all new members have been suspended until the end of the public health emergency. Providers are to complete the IHA when the public health emergency is over. The use of email, telephone, or telehealth to administer the SHA is acceptable.
Health Risk Assessment (HRA)	On March 20, 2020, CMS released a memo to permit Medicare-Medicaid plans to temporarily suspend or limit face-to-face care completion of HRAs and other care coordination activities with enrollees. Plans were required to submit alternative action plans to CMS.
HEDIS measures with telehealth options	The July 1, 2020 release of the NCQA Measurement Year 2020 and 2021 Volume 2 Technical Specifications provided guidance for telehealth options on 40 HEDIS measures. The updates follow CMS guidance on telehealth services and support the increased need for a telehealth option during the pandemic.
Performance improvement activities	DHCS decided to end current performance improvement projects (PIPs) as of June 30, 2020. In mid or late summer, plans will start new PIPs or make adjustments to existing PIPs for plans that choose to continue their strategies and focus.
Facility site reviews and medical record reviews	Per DHCS APL 20-011,2 managed care plans are permitted to suspend contractually required monitoring activities that require in-person site reviews and medical audits of plan providers and subcontractors. DHCS encourages alternative methods to in-person site reviews, such as virtual site reviews.

¹ DHCS APL 20-004 www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2020/APL20-004.pdf

² DHCS APL 20-011 www.dhcs.ca.gov/Documents/COVID-19/APL-20-011-EO-Revision.pdf

Stay informed about COVID-19

For ongoing changes and requirements for COVID-19, visit the following web sites:

• www.ncqa.org/covid
• www.cms.gov/files/document/covid-ma-and-part-d.pdf
• www.dhcs.ca.gov/ Pages/DHCS-COVID‑19-Response.aspx
• CDC.gov/coronavirus
• Health Net’s Covid-19 Provider Alerts web page: provider.healthnet.com, access the Health Net Alerts: COVID-19 link in the yellow bar

Open clinical dialogue

Health Net practitioners and providers are encouraged to talk freely with members about their medical conditions, treatment options and medications, regardless of limits to coverage.

Whole-person strategy

Health Net unifies programs, from wellness to complex care, reflecting Health Net’s commitment to a whole-person strategy. Members who qualify have access to wellness programs, such as obesity prevention and smoking cessation, and chronic conditions management (including in-home biometric devices for qualified members).

Chronic conditions management

The Integrated Care Management program addresses the physical, behavioral and psychosocial needs of the member as part of Health Net’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.

In addition to complex case management and coordination of care services, members with chronic conditions (diabetes, asthma and chronic obstructive pulmonary disease (COPD)) and cardiac conditions (heart failure, coronary artery disease and hypertension) are also managed as part of the Integrated Care Management program.

Health Net 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 member’s plan of care.
• Manage medications and enhance symptom control.
• Educate members about recommended preventive screenings and tests according to national clinical guidelines.
• Encourage the correct use of medications to prevent medication errors.

Providers may contact the Health Net Case Management Department by fax at 1-800-977-7915 for Medicare members who need a referral. Members who want to self-refer to this program may call the toll-free Customer Contact Center number on the back of their Health Net 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 Health Net integrated case management program.

Care reminder messages for members and providers

Care reminder messages are sent when potential gaps in care are found through claims, laboratory data and other sources. These reminders aim to help specific individuals take action and to align with industry-recognized HEDIS measures to improve preventive health, chronic condition management and more.

Health Net care gap reports are available monthly to providers and accompanied by a HEDIS report card so that medical groups can track their performance compared to national benchmarks.* On the member side, Health Net uses the care gap information to send out messaging in modes members prefer, including text messaging, emails, live calls with a clinical pharmacist, and mailings.

*As of June 2020, care gaps will be refreshed twice monthly and pushed to participating primary care physicians (PCPs) via the Cozeva^® provider portal.

Nurse advice line

The nurse advice line is a telephonic support program that enables members to make informed health care decisions. The program offers support for members coping with chronic and acute illness, episodic or injury-related events and other health care issues. Highly trained clinicians are available 24 hours a day, seven days a week in the member’s preferred language to monitor and process health care inquiries.

The nurse advice line staff is trained in telephone triage and may help members with questions and concerns about symptoms, appropriate treatment choices and more.

Decision Power wellness programs

Health Net offers many tools and programs to help members adopt and maintain healthy lifestyles, such as:

• Health Risk Questionnaire (HRQ) – 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 HRQ results that can be printed and shared with their physicians.

• Health record – An online secure database where members can track important medical history, which includes health conditions, immunizations, medications, tests, and procedures. Information from the HRQ automatically becomes part of their personal health records (PHRs). PHRs are auto-populated with member claims and pharmacy data.

• Health promotion programs – These online health improvement programs are comprehensive behavior change programs. They provide information and tools to improve health and reduce disease risk. The programs include achievable goals personalized to individual preferences and interests. Each program focuses on one health topic and includes a to-do list of action items to help individuals reach their goals. Health promotion program topics include stress management, weight loss, nutrition, exercise, and tobacco cessation.

• Quit For Life^® Tobacco Cessation program – Telephonic and online support with a quit coach. Individuals receive one-to-one help during their quit process, a comprehensive quit guide and a guide for family members, unlimited access to online education, and coaching support. Text2Quit messages keep members motivated and on track. Health Net members can register for the Quit For Life telephonic tobacco cessation program by calling
  1-800-893-5597 to speak to an enrollment specialist, or dial directly at 1-866-QUIT-4-LIFE (1-866-784-8454). Additional program and enrollment information is available online at www.healthnet.com > Wellness Center.

• Decision Power^®3 healthy discounts – Health Net members have access to exclusive discounts on eye examinations and eyewear, a weight loss program, vitamins, herbs and supplements, health clubs, and other health-related products and services, including discounts with Jenny Craig^® and Weight Watchers.^®

• Health challenges – Online quarterly challenges to help individuals achieve small changes through healthy eating, exercise, stress management, and weight loss. The duration of each challenge is about one month and offers focused behavior change and record-keeping strategies to help participants stay on track for success.

• Tools to monitor prescription history and check medication interactions; estimated cost of care for more than 100 conditions, 50 procedures or surgeries, and 200 medical tests or visits; compare hospital performance on more than 160 common diagnoses and procedures; and help members understand their health plan options, so they can choose the plans that best fit their families.

Initial health assessments

New Cal MediConnect members must receive an initial health assessment (IHA), which includes an age-appropriate history, physical examination and Individual Health Education Behavioral Assessment (IHEBA) within 120 days after the date of enrollment. In addition to assessing the member’s health, this examination should be used to determine health practices, values, behaviors, knowledge, attitudes, cultural practices, beliefs, literacy levels, and health education needs.

Newly enrolled adult plan members receive preventive services in accordance with the latest edition of the Clinical Preventive Services published by United States Preventive Services Task Force (USPSTF).

The Department of Health Care Services (DHCS) approved IHEBA is the Staying Healthy Assessment (SHA). The SHA is the established assessment tool that enables PCPs to assess members’ current acute, chronic and preventive health needs. The SHA includes standardized questions to assist PCPs in:

• Identifying and tracking high-risk behaviors including smoking and alcohol consumption of individual Cal MediConnect members.
• Assigning priority to individual health education needs related to lifestyle, behavior, disability, environment, culture, and language.
• Initiating discussion, counseling and documenting health education interventions, referrals and follow-up care regarding high-risk behaviors.
• Identifying members whose health needs require coordination with appropriate community resources and other agencies for services not covered under the current contract.

All SHA questionnaires must include the PCP’s name, signature and date. The SHA should be completed at age-related intervals, as appropriate. If a member refuses to complete the SHA, the PCP must make note of the refusal in the member’s medical record.

Providers can access SHA training and download or print electronic versions of the SHA directly from the DHCS website  It is available in nine threshold languages. The SHA is also available in Arabic, Armenian, Chinese, English, Farsi, Hmong, Khmer, Korean, Russian, Spanish, Tagalog, and Vietnamese in the Provider Library under Forms and References (refer to page 13 on how to access the Provider Library). Providers should contact the Health Net Health Education Department at 1-800-804-6074 for more information about SHA.

Health risk assessment

Health Net makes every effort to complete a health risk assessment (HRA) for new Cal MediConnect members within 45 or 90 days of enrollment, depending on risk level, and on an annual basis thereafter. HRAs can be completed more frequently than annually, such as a health status change or by member request. HRA completion helps with early and ongoing identification of member needs, enabling Health Net and participating physician group (PPG) care management teams to develop more comprehensive member-centric care plans. HRAs also help predict future consumption of medical care which is essential to the success of the care management program for both PPGs and Health Net. Health Net contracts with Optum^® to conduct HRAs on its behalf.

Optum tries to complete all HRAs for members identified as high-risk within 45 calendar days of enrollment and for low-risk members within 90 days and annually thereafter. This can be done by telephone, mail or face-to-face. A clinical HRA summary report is developed for each completed HRA and made available to the case manager and PCP via the Health Net Provider Portal at www.provider.healthnet.com. The report supports them in developing a comprehensive care plan using evidence-based alerts. The alerts/flags on the summary report identify areas that warrant prompt attention or monitoring.

If a member cannot be reached after the required attempts to complete an HRA, Health Net will send a letter to the member’s assigned PCP advising that the HRA was not completed.

Community health education programs and services

Health Net’s Health Education Department offers a variety of community health education programs and services to its Cal MediConnect members.

Health education programs

The following health education programs and resources are available for Cal MediConnect members:

• Weight management program – Members have access to Healthy Habits for Healthy People weight management educational resources which include an educational guide, cookbook and exercise band to help older adults and people living with disabilities eat healthy and stay active.

• Healthy Hearts, Healthy Lives program – Members have access to a heart health prevention toolkit (educational booklet and tracking journal) and access to community classes to learn how to maintain a healthy heart.

Health education materials on additional topics are available to members in approved threshold languages upon request. Topics include weight management, diabetes, osteoporosis, advance directive, fall prevention, and more. Providers should contact the Health Net Health Education Information Line at 1-800-804-6074 to request education materials for their sites. Members can also call the Health Net Health Education Information Line at 1-800-804-6074 (TTY: 711) to request materials.

Community classes

Members and the community have access to free health education classes. They are available in many languages and topics which vary by county and are based on the community’s needs. Providers are encouraged to call the Health Education Information Line at 1-800-804-6074 to coordinate health education classes for their sites. Members can also call the Health Net Health Education Information Line at 1-800-804-6074 (TTY: 711) to find classes that may be near their area.

Clinical practice guidelines

Health Net’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 Health Net’s Medical Advisory Council (MAC) adopt the clinical practice guidelines and tools, which are available at provider.healthnet.com under Working with Health Net > Clinical > Medical Policies > Clinical Guidelines. 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 – Decision Power clinical guidelines are available for providers to quickly reference information about a number of chronic conditions, which include heart failure (HF), coronary artery disease (CAD) and diabetes. 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

Health Net’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. Health Net 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 Congress 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 determining factor regarding a member’s care.

Centene’s Clinical Policy Committee and Health Net’s MAC review the preventive health guidelines periodically. The guidelines are available at provider.healthnet.com under Working with Health Net > Clinical > Preventive Health Guidelines. Providers who do not have access to the Internet may contact the Health Net Provider Services Center to request printed copies of these guidelines.

Notification of access standards

Health Net strives to ensure compliance with all applicable state, federal, regulatory, and accreditation requirements to provide members with timely access to care. Health Net regularly monitors the network and evaluates whether members have enough access to practitioners and providers who meet their care needs. Health Net notifies all applicable providers about
Health Net‘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 Cal MediConnect Provider Manual in the Provider Library under Provider Oversight > Service and Quality Requirements > Access to Care and Availability Standards. Refer to page 13 on how to access the Provider Library. 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.

Medical record documentation standards  

Health Net 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. Health Net requires that the practitioner and provider adhere to the standards for maintaining member medical records and safeguard the confidentiality of medical information.

Practitioners and providers are responsible for protecting the confidentiality interests of Health Net members when responding to requests for information. All practitioners and providers must have policies and procedures that address confidentiality and the consequences of improper disclosure of member protected health information (PHI). Refer to the Cal MediConnect Provider Manual in the Provider Library, and go to Medical Records > Confidentiality of Medical Records > Procedure to review specific levels of medical record security that must be addressed by practitioner’s and provider’s policies and procedures governing the confidentiality of medical records and the release of member PHI. Refer to page 13 on how to access the Provider Library.

Health Net monitors medical record documentation compliance and implements appropriate interventions to improve medical record-keeping. Medical record guidelines are available at provider.healthnet.com in the Cal MediConnect Provider Manual in the Provider Library under Medical Records, or upon request by contacting the Health Net Provider Services Center.

Medical record and facility site review

Health Net’s Facility Site Review Compliance Department conducts medical record reviews (MRRs) and facility site reviews (FSRs). These reviews are to measure PCPs’ compliance with current DHCS medical record documentation and facility standards. As part of the credentialing and recredentialing process, these audits are performed prior to admittance to the
Cal MediConnect network and at least every three years thereafter in accordance with DHCS requirements, or on an as-needed basis for monitoring, evaluation or corrective action plans (CAPs). In an effort to decrease duplicative MRRs and FSRs and minimize the disruption of patient care at participating provider offices, Cal MediConnect and Medi-Cal managed care plans are required to collaborate in conducting FSRs and MRRs. On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a PCP and administering a corrective action plan (CAP) when necessary. The responsible plan shares the audit results and CAP with the other participating health plans to avoid redundancy.

Results of each audit are reviewed by the QI Department for compliance with, and maintenance of, standards. Results of the completed site audit are conveyed to the provider and PPG. QI actions are taken as deemed necessary following the audit.

DHCS reviews the results of Health Net’s site reviews and may also audit a random sample of provider offices to ensure they meet DHCS standards. Detailed information about audit criteria, compliance standards, scoring, and CAPs is available at provider.healthnet.com.

Physical accessibility review surveys

A component of the FSR is the Physical Accessibility Review Survey (PARS). PARS is conducted for participating PCPs, high- volume specialists, ancillary providers, and hospitals. All PCP sites must undergo PARS. Based on the outcome of PARS, each PCP site is designated as having basic or limited access along with the specific accessibility indicator designations for parking, exterior building, interior building, restrooms, examination rooms, and medical equipment (accessible weight scales and adjustable examination tables).

Basic access demonstrates facility site access for members with disabilities to parking, building access, elevators, physician’s office, examination rooms, and restrooms. Limited access demonstrates facility site access for members with disabilities as missing or incomplete in one or more features for parking, building access, elevators, physician’s office, examination rooms, and restrooms.

Results of PARS are made available to Health Net’s Cal MediConnect Member Services Department to assist members in selecting a PCP who can best meet their health care needs.

Utilization management

Health Net’s utilization management (UM) program is designed to ensure that members receive timely, medically necessary and cost-effective health care services at the appropriate level of care. The scope of the program includes all members and network providers. Elements of the UM process include prior authorization, concurrent review, discharge planning, care management, and retrospective review.

As part of Health Net’s QI and UM programs, Health Net applies a hierarchy of medical resources for making medical management decisions for Cal MediConnect members. For Medi-Cal-specific benefits, the Health Net medical management team uses medical necessity guidelines from Medi-Cal’s online Provider Manual, Part 2. For Medicare-specific benefits, the medical management team uses Medicare guidelines in the Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations, National Coverage Determination Manual and Local Coverage Determinations documents.

In the event one plan benefit is broader than the other, Health Net applies the broader benefit when making medical management decisions. When this hierarchy of information does not provide documented coverage guidelines, Health Net’s licensed professionals refer to Centene and Health Net’s clinical policies for evidence-based guidelines, which are based on a critical review of published scientific literature pertaining to the efficacy and safety of existing and emerging technologies or new uses of existing technologies.

Clinical policies are used for clinical decision-making as they relate to requests for services or supplies for members. The policies support Health Net’s licensed professionals in making appropriate utilization management or care management decisions. The clinical policies provide guidance as to whether certain services or supplies are cosmetic, medically necessary or appropriate, or experimental and investigational.

The foundation for clinical policies includes evidence based clinical literature and nationally recognized sources, such as:

• Change Health Care InterQual^® medical necessity criteria.
• Hayes Medical Technology Directory.

Quality improvement initiatives

The Quality Improvement (QI) Department utilizes several specific quality initiatives to help improve member health outcomes. Members may receive general or targeted outreach through mailings, emails, live or automated calls 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 Health Net.

Health Net also collaborates with the California Quality Collaborative 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. For a listing of educational programs and patient satisfaction and condition management resources, providers can visit www.calquality.org.

Quality measures and surveys

Health Net measures quality of care and services provided to members in a number of ways, including HEDIS for performance measures for care and service, the CAHPS for annual assessment of member satisfaction, and the Health Outcomes Survey (HOS) for older members. These results enable Health Net to address opportunities for improvement and are the basis for the implementation of various QI initiatives.

Quality and safety reporting

Health Net offers WebMD’s Hospital Advisor Tool, which provides hospital-specific performance findings by diagnosis or procedure, and features metrics including volume, cost, mortality, and complication rates. Data are based on a variety of sources such as safe reporting, survey results 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 provider.healthnet.com under Working with Health Net > Quality > Provider Quality Ratings > Compare Hospitals.

The Leapfrog Group

The Leapfrog Group is a nationwide collaborative effort to promote patient safety and improve quality of care. Since 2014, Health Net has been a Leapfrog Partner and actively works with the Leapfrog Group, its board of directors, and other partners to improve the safety and quality of health care. Health Net currently serves as co-chair of the Leapfrog Group’s Partners Advisory Committee. Health Net’s work as a Leapfrog Partner includes promoting participation in the Leapfrog Hospital Survey, a national rating system that offers consumers key information about a hospital’s quality and safety performance with respect to endorsed patient safety practices and progress toward national quality standards. Measures include:

• Computerized physician order entry.
• Intensive care unit physician staffing.
• Evidence-based hospital referral.
• Safe practices score based on National Quality Forum standards.

Participation in Leapfrog’s survey facilitates hospitals’ ability to assess their strengths and vulnerabilities with respect to meeting quality standards, such as hospital-acquired condition scores and evidence-based care to address common acute conditions. Leapfrog also publishes a Hospital Safety Grade, which assigns each hospital a letter grade to indicate how safely the hospital cares for patients based on an analysis of up to 28 quality measures. For more information about The Leapfrog Group, providers can visit www.leapfroggroup.org.

Office of the Patient Advocate

Office of the Patient Advocate (OPA) publishes reports on quality performance by medical group and health plans, as well as detailed findings about health care complaints filed within the state. OPA’s goal is to better enable health care consumers to access the health care services for which they are eligible. Health Net links to the OPA website via the online provider portal in the Quality Improvement Corner under Working with Health Net > Quality > Provider Quality Ratings > Medical Groups Report Card.

Pharmaceutical management

Health Net pharmaceutical management includes the development and maintenance of the Health Net Cal MediConnect formulary and prior authorization criteria. This information is available to members and participating providers. The Health Net Cal MediConnect formulary serves as a reference for physicians to use when prescribing pharmaceutical products for Health Net Cal MediConnect members. Providers can access the formulary online at mmp.healthnetcalifornia.com > Drug and Pharmacy Information > List of Drugs (Formulary).

The Health Net Pharmacy and Therapeutics (P&T) committee consists of practicing physicians and pharmacists from various specialties. The formulary contains those medications that the P&T Committee has chosen based on their safety and effectiveness as part of the quality treatment program. The P&T Committee reviews and updates the formulary at least quarterly. CMS must also approve of the drugs in the formulary.

Behavioral health services

As appropriate, PCPs provide care for Health Net members who have behavioral health diagnoses. Health Net offers behavioral services from MHN providers. MHN is Health Net’s behavioral health division. Practitioners and providers may refer members for behavioral health services or members can self-refer by calling MHN at the telephone number on their
Health Net ID cards.

For routine behavioral health service requests, MHN 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. MHN’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 within 15 business days with a psychiatrist.

PCPs and their office staff may contact MHN customer service 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 MHN CM. For physicians who need help finding appropriate behavioral health care for their members, MHN customer service representatives can answer questions regarding MHN, its 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 (USPSTF). Newly enrolled Cal MediConnect members are screened for depression through an HRA. Through Health Net’s Decision Power program, clinicians also perform depression screenings for members with chronic medical conditions. Members who screen positive for depression by a clinician may be referred to a participating behavioral health provider for evaluation and follow-up care if indicated, and if the member agrees to the referral. In addition, educational materials about the treatment of depression are available to members through Decision Power and on the Health Net website. Members may call 1-800-893-5597 to speak to a clinician, 24 hours a day, seven days a week.

Depression program

Health Net offers its depression program for most Health Net members. Members newly prescribed with antidepressant medication receive automated IVR calls to educate them about how antidepressants work and the importance of taking medications as prescribed and refilling them, as needed. The calls offer a phone number to call a pharmacist if there are any medication-related questions. The call also offers a live transfer to MHN if members would like to talk to a psychiatrist, therapist, or other behavioral health provider about their medicine.

Most Health Net members appropriately seek depression treatment from their PCPs, which is why Health Net provides physicians and PPGs with the following tool to manage and coordinate care for their patients with depression:

• The MHN/Envolve People Care (EPC) Provider Toolkit – Treating and Managing Behavioral Health Conditions contains information about depression, alcoholism and ADHD along with medication management information and guidelines for sharing information and making referrals. The brochure also includes the Behavioral Health Care Coordination Form, which encourages communication between the behavioral health provider and medical provider.  PCPs and specialists can download the form from the Health Net provider website under Working with Health Net > Quality > Behavioral Health Resources for Health Net Providers.

Additionally, in an effort to increase awareness of the importance of depression identification and management among both providers and members, Health Net has been developing and posting member online news articles to educate members on what depression is, how to recognize it, the availability and types of treatments, and the importance of treatment and antidepressant medication adherence.

MHN Outreach program

The QI Department utilizes several specific quality initiatives to help improve members’ physical and mental health outcomes. The health plan has collaborated with MHN on new quality improvement activities that may reach your office or practices. Note for the Medicare Advantage portion of Cal MediConnect members: Any reference to prescribing ADHD medication to children does not apply.

Overall, members and providers may receive live calls from MHN’s quality team, providing members and providers with important educational information or reminders to take action when necessary. The focus of these initiatives may include antidepressant medication management, follow-up for children prescribed ADHD medication, and coordinating referrals and care. Below is a summary of the collaborative quality improvement projects:

MHN telephonic outreach to –

• Families that have children who are prescribed ADHD medication.
• Physicians who are prescribing ADHD medication.
• Members about antidepressant medication management and the importance of coordination of care.
• MHN written outreach to –
• Physicians about antidepressant medication management and the importance of coordination of care.
• Rights and responsibilities  

Member rights and responsibilities

Health Net 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, Health Net has adopted the following member rights and responsibilities. These rights and responsibilities apply to members’ relationships with
Health Net, its practitioners and providers, and all other health care professionals providing care to its members. The member rights and responsibilities are available in the Cal MediConnect Provider Manual in the Provider Library under Member Rights and Responsibilities, or upon request by contacting the Health Net Provider Services Center. Refer to page 13 on how to access the Provider Library.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1      Being aware of their benefits and services and how to obtain them.

2      Supplying information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.

3      Following plans and instructions for care that they have agreed to with their practitioners.

4      Understanding their health problems and participating in developing mutually agreed-upon treatment goals, to the degree possible.

Members have the right to:

1      Receive information about the organization (including all enrollment notices, and informational and instructional materials), its services, its practitioners and providers, and member rights and responsibilities in a manner and format that may be easily understood.

2      Be treated with respect and recognition of their dignity and right to privacy.

3      Participate in decisions regarding their health care, including the right to refuse treatment.

4      A candid discussion of appropriate medically necessary treatment options for their conditions, regardless of cost or benefit coverage.

5      Voice complaints or appeals about the organization or the care it provides.

6      Make recommendations regarding the organization’s member rights and responsibilities policy.

7      Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

8      Have access to personal medical records, and where legally appropriate, receive copies of, amend or correct their medical record.

9      Reasonable accommodations.

10    Be treated with dignity and respect.

11    Privacy and confidentiality in all aspects of care and for all health care information, unless otherwise required by law.

12    Be provided a copy of their medical records, upon request, and to request corrections or amendments to these records.

13    Not be discriminated against based on race, ethnicity, national origin, religion, gender, age, sexual orientation, medical or claims history, mental or physical disability, genetic information, or source of payment.

14    Have all plan options, rules and benefits fully explained, including through use of a qualified interpreter if needed.

15    Access an adequate network of primary and specialty providers who are capable of meeting their needs with respect to physical access, and communication and scheduling needs, and are subject to ongoing assessment of clinical quality, including required reporting.

16    Choose a plan and provider at any time and have that choice be effective the first calendar day of the following month.

17    Participate in all aspects of care and to exercise all rights of appeal. Members have a responsibility to be fully involved in maintaining their health and making decisions about their health care, including the right to refuse treatment if desired and must be appropriately informed and supported to this end. Specifically, members must:

• Receive a comprehensive health risk assessment within 45–90 days of coverage in a plan and participate in the development and implementation of an individualized care plan (ICP). The assessment must include considerations of social, functional, medical, behavioral, wellness, and prevention domains. The ICP is an evaluation of their strengths and weaknesses, and a plan for managing and coordinating their care. Members, or their designated representative, also have the right to request a reassessment by the interdisciplinary team and be fully involved in any such reassessment.

• Receive complete and accurate information about their health and functional status by the interdisciplinary team.
• Be provided information about all program services and health care options, including available treatment options and alternatives, presented in a culturally appropriate manner, taking into consideration their condition and ability to understand. A participant who is unable to participate fully in treatment decisions has the right to designate a representative. This includes the right to have translation services available to make information appropriately accessible. Information must be available:
  • Before enrollment.
  • At enrollment.
  • At the time needs necessitate the disclosure and delivery of such information in order to allow members to make an informed choice.
• Be encouraged to involve caregivers or family members in treatment discussions and decisions.
• Receive reasonable advance notice, in writing, of any transfer to another treatment setting and justification for the transfer.
• Be afforded the opportunity to file an appeal if services are denied that they think are medically indicated, and to be able to ultimately take that appeal to an independent external system of review.

18    Receive medical and non-medical care from a team that meets their needs in a manner that is sensitive to their language and culture, and in an appropriate care setting, including the home and community.

19    Freely exercise these rights and that the exercise of those rights does not adversely affect the way
Health Net and its providers or DHCS treat them.

20    Receive timely information about the plan changes. This includes the right to request and obtain the information listed in the orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the orientation materials at least 30 days prior to the intended effective date of the change.

21    Be protected for liability for payment of any fees that are the obligation of Health Net.

22    Not to be charged any cost-sharing for Medicare Parts A and B services.

23    The unconditional and exclusive right to hire, fire and supervise their in-home supportive services (IHSS) provider.

24    Receive their Medicare and Medi-Cal appeals rights in a format and language understandable and accessible to them.

25    Opt out of Cal MediConnect at any time, beginning the first of the following month.

In addition:

26    Members shall not be balance billed by a provider for any covered service.

27    Members are free to exercise their rights without negative consequences

Member appeals

A member or a member representative who believes that a determination or application of coverage is incorrect has the right to file an appeal. Health Net has a process in place to record and respond to all member appeal requests. Health Net responds to standard appeals within 30 calendar days after receiving the reconsideration requests (or an additional 14 calendar days if an extension is justified).

If Health Net makes a reconsideration determination on a request for payment that is fully favorable to the member, it must issue a written notice of its reconsideration determination to the member and pay the claim no later than 60 calendar days for Medicare and 30 calendar days for Medi-Cal claims after receiving the reconsideration request. Requests that meet expedited review criteria must be reviewed and resolved within 72 hours of receipt. The 72-hour time frame includes weekends and holidays and begins upon receipt.

Privacy and confidentiality

Health Net members’ PHI, whether it is written, oral or electronic, is protected at all times and in all settings. Health Net 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 Health Net member’s PHI must have a prior, written member authorization.

Health Net practitioners and providers must ensure that only authorized people with a need to know have access to a member’s PHI. Health Net 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. 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

Interpreter services are available at no cost to Health Net 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.

Provider guidelines

• Providers may not request or require an individual with limited English proficiency (LEP) to provide his or her own interpreter.
• Providers may not rely on staff other than qualified bilingual/multilingual staff to communicate directly with individuals with LEP.
• Providers may not request or 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 only 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 telephone number located on the member’s ID card.

Access the Provider Library

Use either option below to access the library:

Option 1 – Log in to the provider website

1    Log in to provider.healthnet.com.

2    From the home page, scroll to the bottom and select the Provider Library tile

Option 2 – Go directly to the Provider Library

1    Go to providerlibrary.healthnetcalifornia.com.

Additional information

More extensive information about all the programs described in this update is available at provider.healthnet.com. A user name and password are required to use the provider website. At the home page under Working with Health Net > Features > Work with Health Net Today, select Register to set up a name and password. Each practitioner or provider office can designate a delegated administrator (usually an information technology, office or security manager) who is responsible for opening accounts and monitoring employee-level access to the practitioner and provider information on the site.

Practitioners and providers who do not have access to the Internet may request printed copies of practitioner and provider materials by contacting the Health Net Provider Services Center. A complete copy of Health Net’s QI program description is available on request by sending an email to the QI Department.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by county within 60 days at:

Line of Business	Telephone Number	Email Address
Cal MediConnect – Los Angeles County	1-855-464-3571	provider_services@healthnet.com
Cal MediConnect – San Diego County	1-855-464-3572

³Health Net Community Solutions, Inc. (Health Net) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees in Health Net’s Cal MediConnect Plan. Decision Power^® services, including its clinicians, are additional resources that Health Net makes available to its Cal MediConnect Plan enrollees. It is not affiliated with Health Net’s provider network. Decision Power is neither offered nor guaranteed under Health Net's Cal MediConnect Plan (Medicare-Medicaid Plan) contract with Medicare or Medi-Cal, and it may be revised or withdrawn without notice. Decision Power services are not subject to the Medicare appeals process. Disputes regarding products and services may be subject to Health Net’s grievance process.