CurrentHealth NetPolicy N/A

Case Management

Describes criteria and processes for screening members for case management services and how case managers coordinate care; applies to Health Net members covered by Health Net of California entities.

Policy Summary

PayerHealth Net

PolicyCase Management

Policy CodePolicy N/A

Change TypeMinor / No material changes

Effective DateN/A

Next Review DateN/A

Key ActionScreen members for case management if they meet listed utilization, eligibility, pregnancy risk, clinical trial, referral, or health risk questionnaire criteria and contact Case Management via the provided email or fax.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2+hospitalizations within six months triggers screening

3+ER visits within six months (for same condition) triggers screening

AllWellcare Specialty assigned care manager

800-745-6955Case Management fax

Case.Management Referrals@healthnet.comCase Management email

Case Management Screening Criteria

Members meeting any of the following should be screened for case management services:

ANY of the following

ANY of the following
- Two or more hospitalizations within six months
- ANY of the following
  - Three or more ER visits for the same condition within six months
  - Two hospital admissions for the same condition within six months

Policy Summary

PayerHealth Net

PolicyCase Management

Policy CodePolicy N/A

Change TypeMinor / No material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Utilization Thresholds and Coding Notes

Not specifiedmixed

No codes listed

inv-03: Hospitalizations threshold

Threshold2 or more hospitalizations within six months

ContextTriggers screening for case management services for members experiencing catastrophic or chronic conditions

Source guidanceListed under Case Management screening criteria in the policy

inv-04: ER visits threshold (same condition)

Threshold3 or more ER visits for the same condition within six months

Alternate trigger2 hospital admissions for the same condition within six months

ContextUsed to identify members for case management screening

inv-05: ER visits threshold (multiple conditions)

ThresholdMultiple ER visits for multiple conditions within six months (document text does not specify exact numeric count)

ContextIncluded as a utilization trigger for case management screening alongside other utilization and eligibility indicators

NotePolicy language is unclear on the exact count; treat as a flag requiring case-by-case review or clarification

Screening and Referral Process

Prior Authorization

Case Management screening and referral requirements

Screen members for case management when they meet utilization, eligibility, clinical trial, pregnancy risk, health questionnaire, or referral criteria; contact Case Management by email or fax to make referrals.

Screen if member has two or more hospitalizations within six months.
Screen if member has three or more ER visits, or two hospital admissions, for the same condition within six months.
Screen if member has multiple ER visits for multiple conditions within six months.
Screen members eligible for public health programs or accepted into clinical trials.
Screen pregnant members with high-risk conditions and members identified via the health risk questionnaire.
Refer members identified or referred from the Case Management Department by emailing Case.Management Referrals@healthnet.com or faxing 800-745-6955.

Roles and Eligibility Indicators

inv-07: Case manager

Primary roleCoordinate care for medically catastrophic cases in cooperation with the provider to achieve optimum care and coverage benefits for the member

Key responsibilitiesWork with members, caregivers, physicians and other care team members to manage care

Delegation optionResponsibilities may be performed by delegated participating physician groups (PPGs)

Assignment noteAll Wellcare Specialty No premium members are assigned a care manager upon enrollment

inv-08: Eligibility indicators

Clinical trial participationMembers accepted into clinical trials are screened for case management

Public program eligibilityMembers who are eligible for public health programs are screened for case management

High-risk pregnancyPregnant members with high-risk conditions are screened for case management

Health risk questionnaireMembers identified through the health risk questionnaire process are screened for case management

ReferralMembers referred from the Case Management Department are included as eligibility indicators