22-273 Complete Required Training to Ensure Proper Medical Necessity Determination

Date: 03/31/22

This information applies to Physicians and Participating Physician Groups (PPGs).

Staff who perform utilization review for gender affirming procedures must complete WPATH training

As noted in provider update 21-793, Medical Necessity Criteria for Treatment of Gender Dysphoria, participating physician groups (PPGs) delegated for utilization management must use the World Professional Association for Transgender Health (WPATH) criteria when determining medical necessity for gender affirming procedures.

To ensure proper application of the criteria, anyone who makes medical necessity decisions for Health Net members – for gender affirming procedures – must complete the required training directly from WPATH.

Training access

Health Net has collected the contact information for the decision makers from delegated PPGs and submitted it to WPATH to create training accounts. Once an account is created, each trainee will receive an email directly from WPATH, with login information and instructions on how to complete the required training. Trainees should complete the training as soon as possible following enrollment to ensure compliance.

Training requirements

Once enrolled, each trainee has 12 months to complete all required trainings and pass the Inter-Rater Reliability (IRR) test.

Required training includes:

• Recorded didactic sessions:
  • Must be completed before attending the livestreamed panel training.
• Livestreamed panel:
  • Facilitated throughout the year to accommodate schedules.
  • Includes a multi-specialty panel discussion and question & answer (Q&A) session.

Once the WPATH training is completed, each trainee must pass an IRR test on use of the WPATH criteria. The IRR testing should include:

• Examples/scenarios that would require the application of WPATH criteria.
• Scenarios that come from actual examples your organization has processed previously or mock scenarios created for your IRR process.

Completion of the training requirements and IRR testing will be validated as part of your annual utilization management compliance audit.

Additional training is required when WPATH releases updated versions of the criteria. Providers can find links to WPATH training materials and training course information on the Health Net provider portal at provider.healthnet.com > Resources For You.

Trainings for new staff

Going forward, any new staff responsible for making decisions using WPATH criteria will need to complete the required training and pass an IRR test before permitted to independently complete medical necessity review on these requests. Each PPG is responsible for ensuring that any staff who make medical necessity determinations or perform utilization review complete required training.

Health Net will receive updates on training progress throughout the year from WPATH. Health Net will use the training updates to validate requirement completion for each delegated PPG as part of the annual utilization management compliance audit.

To request training for new staff members or cancel training, email for assistance. Be sure to provide the staff member’s first and last name, business title and their email address.

Training costs

Health Net is responsible for training costs for the identified decision makers only. If PPGs would like to train additional staff other than the identified decision makers, it would be at the PPG’s cost. Please visit WPATH for more enrollment information.

Additional information

Please contact by email with questions about WPATH training requirements.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider website.