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[PLEASE REVIEW BEFORE SENDING – Directions for staff sending the agreementIf PPG is not delegated for CCM or SNP, please remove entire section for Complex CaseManagement pg 12-14, Special Needs Program Case Management pg 15-36 and revisedelegation grid header as applicable.]If PPG does not have Medicare LOB, please delete the lines on page 7 and 8 related toMedicare-certified facilitiesIf PPG does not have Community Care (Exchanges) LOB, please delete “MUST UTILIZEHEALTH NET’S PRIOR AUTHORIZATION LIST FOR COMMUNITY CARE HMO MEMBERSONLY” from pages 6, 8 and 9 Date «Contact Name»«Contact Title»«Address»«City», «State» «Zip»Sent via «Email»:Re:Provider Delegation Agreement«PPG Name» #«Commercial PPG»Dear «Contact Name»:Health Net of California, Inc., (Health Net) Delegation Oversight Committee has reviewed andaccepted the documentation and findings from your annual assessment. You have met HealthNet’s criteria for the delegation of Utilization Management/Complex Case Management(CCM)/Special Needs Program (SNP) in connection with your Health Net Provider ParticipationAgreement.Please have an authorized representative (Medical Director or Administrator) review and sign theenclosed “Provider Delegation Agreement” and return it to Health Net by Date, 15 calendardays from the date of the letter . Please retain a copy for your files.Attached is the delineation of delegated Utilization Management, CCM and SNP responsibilities.Health Net will continue to oversee your delegated activities. I will work with you on an on-goingbasis during the upcoming year to monitor your compliance with the delegated activities and toassist you with corrective actions as appropriate. Health Net agrees to provide available memberexperience data related to PPG’s performance of utilization management and case managementfunctions to the PPG on request.If you have any questions, please call me at insert MPM phone number or e-mail me at insertMPM email address @healthnet.com. Congratulations on your successful management ofdelegated responsibilities and thank you for your cooperation and support.Sincerely,Clinical Compliance AuditorDelegation OversightHealth Net of California, Inc.UM PDAT Delegation AgreementFile Year: 2017
Attachments: Provider Delegation AgreementUM PDAT Delegation AgreementFile Year: 2017
Provider Delegation AgreementIn connection with its Health Net of California, Inc., (“Health Net”) Provider ParticipationAgreement, «PPG Name» agrees to accept responsibility for delegation of UtilizationManagement/CCM/SNP activities (per the attached grid).Effective «audit or contract date», «PPG Name» agrees to comply with the responsibilities(including the performance requirements) set forth in the Health Net / Participating PhysicianGroup / Provider Delineation of Delegated Utilization Management/CCM/SNP Responsibilitiesgrid. Health Net may determine that a periodic visit is indicated. In such case, Health Net willcontact you to establish a time and date for the visit. At a minimum, Health Net will schedule anannual visit to evaluate the delegated activities.In compliance with accreditation standards and regulatory requirements «PPG Name» shall notrestrict the rights and obligations of Member Physician to communicate freely with Membersregarding their medical condition and treatment alternatives, including medication treatmentoptions, regardless of benefit coverage limitations.«PPG Name» (if contracted to serve Medicare Advantage members) recognizes its responsibilityto conform to the delegation requirements in a manner consistent with CMS regulations.«PPG Name» agrees to abide by mutually agreed upon corrective action plans. In the event that«PPG Name» does not perform the delegated responsibilities as defined in the attached HealthNet / Participating Physician Group / Provider Delineation of Delegated UtilizationManagement/CCM/SNP Responsibilities grid, and in accordance with Health Net, NCQA andregulatory standards, Health Net reserves the right, upon written notice, to revoke the delegationof some or all these responsibilities for Health Net members as set forth herein. Except in theevent of risk to Members, «PPG Name» will be provided a thirty- (30) day cure period prior todelegation being revoked.This agreement shall remain in effect unless the «PPG Name» is notified otherwise by HealthNet.Health Net of California, Inc.Date: insert DOC approval date Elaine Robinson-Frank RN, MPHVice President Delegation Oversight«PPG Name» #«Commercial PPG»SignatureDate:Please Print Signer’s Name and Title HerePlease sign and return one copy of this agreement by Date, 15 calendar days from thedate of the letter to:Health Net of California, Inc. CCA name , Clinical Compliance AuditorM/S: CA-116-02-02 650 East Hospitality LaneUM PDAT Delegation AgreementFile Year: 2017
San Bernardino, CA 92408 Via email: MPM Email Address UM PDAT Delegation AgreementFile Year: 2017
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesDelegate Name:«PPG Name»Delegation Date:«audit or contract Date»Commercial HMO Delegate # «Commercial PPG»Seniority Plus Delegate# «Seniority Plus PPG»Medi-Cal Delegate# «Medi-Cal PPG»Community Care Delegate# «Commercial PPG»Sapphire Delegate #«Seniority Plus PPG»ActivitiesDelegate ResponsibilitiesDelegateStatusFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)Health Net’s Processfor EvaluatingDelegate’sPerformanceCorrective Actions ifDelegate Fails toMeet ResponsibilitiesUtilization ManagementUM ProgramYesNo Develop, implement and submitto Health Net a UtilizationManagement Plan/Programoutlining program structure,accountability, scope, criteria,and process used to makedeterminations of benefitcoverage and medical necessity.Establish Behavioral Healthaspects of the UM Program (ifapplicable)Establish policies and proceduresto assure that appropriatelylicensed professionals superviseall medical necessity decisions. Ensure appropriate licensedpractitioners make all medicalnecessity denial determinations. Ensure a senior physician, withan unrestricted license, hassubstantial involvement in UMProgram and implementation. Ensure involvement of adesignated behavioral healthcarepractitioner in the implementationof the behavioral healthcareaspects of the program (ifapplicable). Have written UM decision-makingAnnually:Monitor and oversee delegatedfunction to ensure standards aremet. UM ProgramDescription UM Program Evaluation UM Work planCommercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/ReportsMedi-Cal Delegates Only:Quarterly: ICE UM Workplan/ReportsDelineation of Delegated Utilization Management ResponsibilitiesFile Year: 20185 Initial assessmentutilizing HealthNet ProviderDelegationAssessment Tool(PDAT). Annualassessmentutilizing HealthNet ProviderDelegationAssessment Tool(PDAT). RequireCorrective ActionRequest(s) forelements of non compliance. Potentialrevocation of UMdelegation if CAPobjectives are notachieved. Continuednoncompliancemay lead to abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesDelegateStatusDelegate ResponsibilitiesFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)Health Net’s Processfor EvaluatingDelegate’sPerformanceCorrective Actions ifDelegate Fails toMeet Responsibilitiescriteria that are objective andbased on medical evidence,criteria is reviewed annually andalso the procedures for applyingthe criteria.Prospective ReviewOther Infusion / HomeHealth stheticOutpatientSurgeries Establish policies and proceduresto meet communication servicesfor members and practitioners toinclude access to staff during andafter business hours. Evaluate UM Program annually.Conduct pre-certification reviewsfollowing Health Net policies andmembers benefit package per theHealth Net Participating ProviderAgreement (PPA) PPA.Utilizes nationally recognized UMdecision-making criteria that areobjective and based on medicalevidenceDevelop written policies andprocedures for applying the criteriabased on individual needs to includeassessment of the local deliverysystem.Commercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/ReportsMedi-Cal Delegates Only:Establish, publish and distributeperformance standards andguidelines to providers that areconsistent with Federal and Staterequirements, and NCQAstandards. Initial assessmentutilizing HealthNet PDAT. Annualassessmentutilizing HealthNet PDAT.Quarterly:ICE UM Work plan/ReportsInclude the number ofapprovals and denialsgenerated by the delegatedentity.Specialty Referral reportsquarterlyMUST UTILIZE HEALTH NET’SPRIOR AUTHORIZATION LIST FORCOMMUNITY CARE HMO MEMBERSONLYDelineation of Delegated Utilization Management ResponsibilitiesFile Year: 20186 Focused reviewsto measure areasof noncomplianceas warranted. RequireCorrective ActionRequest(s) forelements of non compliance. Potentialrevocation of UMdelegation if CAPobjectives are notachieved. Continuednoncompliancemay lead to abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesDelegateStatusDelegate ResponsibilitiesFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)Prospective oHospice (If byDoFR hospice is acarve out, delegateis responsible forservices not relatedto hospice)Conduct pre-certification followingHealth Net policies and member’sbenefit package and per the PPA.Utilizes nationally recognized UMdecision-making criteria that areobjective and based on medicalevidenceDevelop written policies andprocedures for applying the criteriabased on individual needs to includeassessment of the local deliverysystem.Commercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/ReportsMedi-Cal Delegates Only:Quarterly: ICE UM Workplan/ReportsMUST UTILIZE HEALTH NET’SPRIOR AUTHORIZATION LIST FORCOMMUNITY CARE HMO MEMBERSONLYDelineation of Delegated Utilization Management ResponsibilitiesFile Year: 20187Establish, publish anddistribute performancestandards and guidelines toproviders that are consistentwith Federal and Staterequirements, and NCQAstandards.Monitor and overseedelegated function to ensurestandards are met.Health Net’s Processfor EvaluatingDelegate’sPerformance Review ICE UMWork plan/reportswith writtenevaluationprovided toDelegate. Initial assessmentutilizing HealthNet PDAT. Annualassessmentutilizing HealthNet PDAT. Focused reviewsto measure areasof noncomplianceas warranted.Corrective Actions ifDelegate Fails toMeet Responsibilities RequireCorrective ActionRequest(s) forelements of non compliance. Potentialrevocation of UMdelegation if CAPobjectives are notachieved. Continuednoncompliancemay lead to abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesDelegateStatusDelegate ResponsibilitiesFrequency of ReportingDelegated(Yes)orNot Delegated(No)The followingprocedures must beperformed atMedicare-certifiedfacilities:Carotid arterystentingLung-volumereduction surgeryVentricularassist device (VAD)destination therapyYesNoHealth Net participating providersmust first confirm that the facility isparticipating with Health Net. Then,providers must refer to theCMS website sp to ensure the facility isMedicare-certified to perform thespecified procedure. Once on theCMS website, providers shouldconsult the list in the left-hand menubar for information on the applicableprocedure.Delineation of Delegated Utilization Management ResponsibilitiesFile Year: 20188Health Net’s ResponsibilitiesHealth Net’s Processfor EvaluatingDelegate’sPerformanceCorrective Actions ifDelegate Fails toMeet Responsibilities
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesDelegateStatusDelegate ResponsibilitiesFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)Concurrent Review Conduct onsite and/or telephonicUtilization Managementconcurrent reviews as per thePPA. Conduct inpatient casemanagement for high-risk and /or catastrophic cases.InpatientAcuteYesNoSNFYesNoYesNoHospice (If byDoFR hospice is acarve out, delegateis responsible forservices not relatedto hospice) Identify discharge-planning needsprior to discharge and make allnecessary arrangements formembers.Coordinate activities with HealthNet’s Care managers andAncillary Providers as requestedand/or required.Utilizes nationally recognizedUM decision-making criteria thatare objective and based onmedical evidenceWeekly inpatient logsidentifying denials of care toinclude admission anddischarge date and specificreasons for denial of daysand/or levels of care.Commercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/Reports Monitor and overseedelegated function to ensurestandards are met. Track and compareprovider’s performance tothat of the regions, networkand top performingproviders.Medi-Cal Delegates Only:Quarterly: Establish, publish anddistribute performancestandards and guidelines toproviders that are consistentwith Federal and Staterequirements, and NCQAstandards.ICE UM Workplan/ReportsDevelop written policies andprocedures for applying thecriteria based on individual needsto include assessment of thelocal delivery system.Health Net’s Processfor EvaluatingDelegate’sPerformance Review ICE UMWork plan/reportswith writtenevaluationprovided toDelegate. Initial assessmentutilizing HealthNet PDAT. Annualassessmentutilizing HealthNet PDAT annualaudit tool. Review ofDelegates basedon identifiedover/underutilization trendsas established byHealth Net. Corrective Actions ifDelegate Fails toMeet Responsibilities RequireCorrective ActionRequest(s) forelements of non compliance. Health Net toconducttelephonic or onsite UM reviewswhen warranted. Potentialrevocation of UMdelegation if CAPobjectives are notachieved withinagreed timeframe. Continuednoncompliancemay lead abreach of the PPAand subsequenttermination of thePPA. RequireCorrective ActionRequest(s) forelements of non compliance. Potentialrevocation of UMdelegation if CAPFocused reviewsto measure areasof noncomplianceas warranted.MUST UTILIZE HEALTH NET’SPRIOR AUTHORIZATION LIST FORCOMMUNITY CARE HMO MEMBERSONLYRetrospectiveReview{professional anddiagnostic services}ER servicesInpatientServices YesNoYesNo Conduct retrospective review onindividual cases and aggregatedecision data to identify specificissues arising from an episode ofcare (e.g. ER claims).Communicate identified issues torespective providers.Commercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/ReportsMedi-Cal Delegates Only:Quarterly:Delineation of Delegated Utilization Management ResponsibilitiesFile Year: 20189 Monitor and overseedelegated function to ensurestandards are met. Collect Delegate specificencounter data andcompare to plan-wide datato identify more effectivemethods of managing ofReview monthlyencounter data.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesDelegateStatusDelegate ResponsibilitiesFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)OutpatientServicesYesNo Submit all encounter data. Follow prudent laypersonstandard as set forth by CAHealth and Safety Code section1371.4 (c) and NCQA standardUM 12A when reviewing allemergency services. ICE UM Workplan/ReportsHealth Net’s Processfor EvaluatingDelegate’sPerformanceCorrective Actions ifDelegate Fails toMeet Responsibilitieshealth care resources.objectives are notachieved withinagreed timeframe. MUST UTILIZE HEALTH NET’SPRIOR AUTHORIZATION LIST FORCOMMUNITY CARE HMO MEMBERSONLYDelineation of Delegated Utilization Management ResponsibilitiesFile Year: 201810Continuednoncompliancemay lead abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesDelegateStatusDelegate ResponsibilitiesFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)Case ManagementAmbulatoryYesNoDenial of Servicefor MedicalNecessity/ NoYesNoSNF Services Develop process to includepolicies and procedures forambulatory case management. Conduct ambulatory casemanagement/care coordinationon patient population based onneed. Ensure process forapplying the criteria is based onindividual needs to includeassessment of the local deliverysystem. Refer high risk/catastrophicmembers to Health Net for casemanagement if applicable Ensure process reviews themember’s individual needsencompassing overall healthstatus, family support, communityresources available.Commercial and MedicareAdvantage Semi-Annually: Establish standards for denial ofservices, process of denial,notification of denial, andtimeliness of denials as per thePPA and applicable Federal andState requirements, and NCQAstandards.Commercial and MedicareAdvantage Semi-Annually:Issue first level denials on thebasis of clinical data reviewed orcoverage limitation.Quarterly: Provide Health RiskAssessment and otherpredictive indicators to theDelegate. Health Net to providereferral form and definitionsfor referral of complexmembers for casemanagement if applicable Provide additional caremanagement support toDelegate as requested. Monitor and overseedelegated function to ensurestandards are met.Quarterly:ICE UM Work plan/Reports No Medi-Cal Delegates Only:Coordinate activities with HealthNet’s Care Managers andAncillary Providers as indicated. Establish, publish anddistribute information toidentify and manage highrisk/high cost diagnoses.ICE UM Workplan/Reports No ICE UM Workplan/ReportsMedi-Cal Delegates Only: ICE UM Workplan/ReportsEnsure denial files include allpertinent clinical information,specific criteria cited, physicianinvolvement in denialdeterminations, alternativetreatment plan, how member canEstablish, publish and distributeperformance standards andguidelines to providers that areconsistent with Federal and Staterequirements, and NCQAstandards.Health Net’s Processfor EvaluatingDelegate’sPerformance Review of ICE UMWork plan/reportswith writtenevaluation sentback to Delegate. Health Net mayconduct review toreassess areas ofnon-compliance. Review of ICE UMWork plan/reportswith writtenevaluation sentback to Delegate. RequireCorrective ActionRequest(s) forelements of non compliance. Initial assessmentutilizing HealthNet PDAT. Annualassessmentutilizing HealthNet PDAT forreview of denialfiles.Health Net mayconduct review toreassess areas ofnon-compliance. Health Net mayput Delegate onprospective/retrospective review ofall service denialletters. Potential Delineation of Delegated Utilization Management ResponsibilitiesFile Year: 201811Corrective Actions ifDelegate Fails toMeet ResponsibilitiesFocused reviewsto measure areas
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesDelegateStatusDelegate ResponsibilitiesFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)Infusion / HomeHealth ls andGrievancesNoExperimental andInvestigationalProceduresNot a delegatedfunction.NoHealth Net’s Processfor EvaluatingDelegate’sPerformanceCorrective Actions ifDelegate Fails toMeet Responsibilitiesof noncomplianceas warranted.revocation of UMdelegation if CAPobjectives are notachieved withinagreed timeframe.obtain a copy of the criterionused to make the determinationand required appeal language toinclude the expedited externalreview process. Monitor denial activity throughUM Committee. Instruct member to contact Health Netfor all appeals and grievances.N/AConduct all member appeals andgrievances Immediately forward all pertinentdocumentation for investigationalor experimental treatment toHealth Net.N/A Review request and issueresponse per Health Netpolicy.Retain responsibility for caremanaging member and assistingmember in obtaining routineservices within network ifmember is in clinical trial. If denied, refer for third partyreview. Inform member andDelegate of results of thirdparty review.Not a delegatedfunction.Delineation of Delegated Utilization Management ResponsibilitiesFile Year: 201812N/AN/AN/AN/AContinuednoncompliancemay lead abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesCase Management– Complex CaseManagementMemberIdentificationDelegate ResponsibilitiesDelegateStatusDelegated(Yes)orNot Delegated(No)YesNo Identify high risk members whomight benefit from casemanagement services utilizingscreening criteria, addressmembers as identified by HealthNet in the Operations Manual.Establish multiple avenues formembers to be considered forcomplex case managementincluding active participation inHealth Net member identificationprocess (Health Risk Assessment(HRA) and other predictivemodeling processes). Assesses the characteristics andneeds of its member population. Reviews and updates the CMprocesses to address memberneeds. Establish and utilize a casemanagement system that: Uses evidence basedclinical guidelines forassessment andmanagement of members. Documents date and time ofstaff interventions. Have automated prompts forfollow-up with members.Frequency of ReportingCase Management Files arereviewed at the time of theannual audit and as deemednecessary.Semi-annual reporting toHealth Net on cases referredto Delegate through HealthNet member identificationprocessCommercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/ReportsDelineation of Delegated Utilization Management ResponsibilitiesFile Year: 201813Health Net’s Responsibilities Establish, publish anddistribute performancestandards and guidelines toproviders that are consistentwith Federal and Staterequirements, and NCQAstandards.Provide Health RiskQuestionnaire and otherpredictive indicators to theDelegate.Health Net’s Processfor EvaluatingDelegate’sPerformance Annualassessmentutilizing HealthNet PDAT. DelegateMeetings. Ongoing feedbackon identified highrisk members;may include but isnot limited tocompletingfeedback grid orparticipating incase conferences.Monitor and overseedelegated function to ensurestandards are met. Focused reviewsto measure areasof noncomplianceas warranted.Corrective Actions ifDelegate Fails toMeet Responsibilities RequireCorrective ActionRequest(s) forelements of noncompliance. Health Netprovides trainingas warranted. Potentialrevocation of CMdelegation if CAPobjectives are notachieved withinagreed timeframe. Continuednoncompliancemay lead abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesCase Management– Complex CaseManagementCase ManagementProcessDelegate ResponsibilitiesDelegateStatusDelegated(Yes)orNot Delegated(No)YesNoEstablish and maintain proceduresthat address: Member’s rights to decline ordisenroll from case management. Documentation of clinical historyincluding medications andcondition specific issues. Initial assessments of: Activities of Daily Living mental health statusincluding cognitive functions life planning activitiesEvaluation of: cultural and linguistic needs visual and hearing needs care giver resources andinvolvement available benefits within theorganization and fromcommunity resourcesFrequency of Reporting Case Management Files are reviewed at the timeof the annual audit and asdeemed necessary. Semi-annual reporting toHealth Net on casesreferred to Delegatethrough Health Netmember identificationprocess.Commercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/ReportsA Care Management planincluding prioritized goalsincluding those of thecaregivers and desired levelof involvement, and barriersto meeting those goals. A schedule for regular followup and communication withmembers. A plan to communicate tomember a selfmanagement plan. Establish, publish anddistribute performancestandards and guidelines toproviders that are consistentwith Federal and Staterequirements, and NCQAstandards.Provide Health RiskQuestionnaire and otherpredictive indicators to theDelegate.Health Net’s Processfor EvaluatingDelegate’sPerformance Annualassessmentutilizing HealthNet PDAT. DelegateMeetings. Ongoing feedbackon identified highrisk members;may include but isnot limited tocompletingfeedback grid orparticipating incase conferences.Monitor and overseedelegated function to ensurestandards are met. Development of: Health Net’s ResponsibilitiesAssessing member’s progressagainst the care managementplan.Delineation of Delegated Utilization Management ResponsibilitiesFile Year: 201814Focused reviewsto measure areasof noncomplianceas warranted.Corrective Actions ifDelegate Fails toMeet Responsibilities RequireCorrective ActionRequest(s) forelements of noncompliance. Health Netprovides trainingas warranted. Potentialrevocation of CMdelegation if CAPobjectives are notachieved withinagreed timeframe. Continuednoncompliancemay lead abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesActivitiesCase Management– Complex CaseManagementSatisfaction withand MeasuringEffectivenessDelegate ResponsibilitiesDelegateStatusDelegated(Yes)orNot Delegated(No)YesNoEstablish and maintain proceduresthat address:SATISFACTION Obtaining feedback frommembers and analyzing suchfeedback.Frequency of Reporting Case Management Files are reviewed at the timeof the annual audit and asdeemed necessary. Semi-annual reporting toHealth Net on casesreferred to Delegatethrough Health Netmember identificationprocess.MEASURING EFFECTIVENESSMeasuring the effectiveness of casemanagement program using 3measures selected by Delegate basedon the review of their casemanagement program. For each suchmeasure the Delegate: Identifies relevant processes oroutcomes Uses valid methods that providequantitative results Sets performance goals Identifies clearly measurespecifications Analyzes results Identifies opportunities forimprovement Plans for intervention and remeasurementCommercial and MedicareAdvantage Semi-Annually: ICE UM Workplan/ReportsImplementing at least oneintervention to improveperformance based on criteriaabove. Re-measuring to determineperformance. Establish, publish anddistribute performancestandards and guidelines toproviders that are consistentwith Federal and Staterequirements, and NCQAstandards.Provide Health RiskQuestionnaire and otherpredictive indicators to theDelegate.Health Net’s Processfor EvaluatingDelegate’sPerformance Annualassessmentutilizing HealthNet PDAT. DelegateMeetings. Ongoing feedbackon identified highrisk members;may include but isnot limited tocompletingfeedback grid orparticipating incase conferences.Monitor and overseedelegated function to ensurestandards are met. ACTION AND REMEASUREMENT Health Net’s ResponsibilitiesDelineation of Delegated Utilization Management ResponsibilitiesFile Year: 201815Focused reviewsto measure areasof noncomplianceas warranted.Corrective Actions ifDelegate Fails toMeet Responsibilities RequireCorrective ActionRequest(s) forelements of non compliance. Health Netprovides trainingas warranted. Potentialrevocation of CMdelegation if CAPobjectives are notachieved withinagreed timeframe. Continuednoncompliancemay lead abreach of the PPAand subsequenttermination of thePPA.
Participating Physician Group / ProviderDelineation of Delegated Utilization Management [/CCM/SNP] ResponsibilitiesDelegationDate:Delegate Name:Dual Eligible (DSNP)Chronic Special Needs Plan (CNSP)ActivitiesDelegate ResponsibilitiesDelegate SNPStatusFrequency of ReportingHealth Net’s ResponsibilitiesDelegated(Yes)orNot Delegated(No)Targeted SpecialNeeds IndividualsYesNoDelegate has a model of care tomanage the delivery of specializedservices and benefits for:Annually: Dual-eligible special needsindividuals (DSNP)UM/SNP Program Evaluation Individuals with chronicconditions (CSNP)Semi-annually: Meets all of the standards forComplex Case Management asset forth in NCQA PHM and SNPstandards as set forth by CMS. Delegate has written care planson 100% of its members Delegate has an InterdisciplinaryCare Team (ICT) meeting on100% of its members at aminimum of annually. Establish, publish anddistribute to providersperformance standards andguidelines that areconsistent with CMS SNPrequirements Review UM/SNPWork plan/reportswith writtenevaluationprovided toDelegate. Monitor and overseedelegated function toensure standards are met. Initial assessmentutilizing HealthNet SNP ProviderDelegationAssessment Tool(PDAT). Annualassessmentutilizing HealthNet SNP PDAT. Focused reviewsto measure areasof noncomplianceas warranted.UM/SNP ProgramDescription or P&PsICE UM/SNP Workplan/ReportsDelineation of Delegated Utilization Management ResponsibilitiesFile Year: 201816Health Net’s Processfor EvaluatingDelegate’sPerformanceCorrective Actions ifDelegate Fails toMeet Responsibilities RequireCorrective ActionRequest(s) forelements of non compliance. Potentialrevocation of SNPCareManagementdelegation if CAPobjectives are notachieved. Continuednoncompliancemay lead to abreach of
Sapphire Delegate #«Seniority_Plus_PPG» Activities . Delegate Status Delegated (Yes) or Not Delegated (No) Delegate Responsibilities Frequency of Reporting Health Net’s Responsibilities Health Net’s Process . Yes No Health Net participating providers must first confirm that the facility is participating with
