21-793 Medical Necessity Criteria for Treatment of Gender Dysphoria
Date: 11/04/21
This information applies to Participating Physician Groups (PPGs).
Use WPATH nonprofit clinical criteria to determine medical necessity for members diagnosed with gender dysphoria
Effective January 1, 2021, Senate Bill 855 (Chapter 151, statutes of 2020, section 1374.721), requires health plans to use the most recent criteria and guidelines developed by the nonprofit professional association for the relevant clinical specialty.
The nonprofit criteria and guidelines are in the Standards of Care (SOC), located on the World Professional Association of Transgender Health (WPATH) website at www.wpath.org/publications/soc.
PPG requirements
Participating physician groups (PPGs) delegated for utilization management are required to:
- Use the nonprofit criteria to determine medical necessity for gender affirming procedures, when such services are included under the members’ benefit plan and subject to applicable state and federal laws.
- Determine medical necessity on an individualized basis.
- Include the criteria and guidelines from the WPATH SOC in decision making hierarchy and document that hierarchy in appropriate policies. You can find the criteria and guidelines on the provider portal, under Resources for you, select Medical Policies.
Required training
Training on how to use WPATH guidelines will be communicated at a later date.
Health Net will work with its PPGs to determine which staff, who make medical necessity determinations or perform utilization review, will require formal training on how to use WPATH criteria. Health Net will also notify PPGs about training materials and resources that are available to members and providers.
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 | ||
EnhancedCare PPO (SBG) | 1-844-463-8188 | provider_services@healthnet.com | |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider_services@healthnet.com | |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | provider_services@healthnet.com | |
Medicare (individual) | 1-800-929-9224 | provider_services@healthnet.com | |
Medicare (employer group) | 1-800-929-9224 | provider_services@healthnet.com | |
Medi-Cal | 1-800-675-6110 | N/A | |
| Cal Mediconnect – Los Angeles County | 1-855-464-3571 | N/A | provider_services@healthnet.com |
| Cal Mediconnect – San Diego County | 1-855-464-3572 | N/A | provider_services@healthnet.com |