CurrentmhnPolicy N/A

Case Management

Describes criteria and referral process for screening members for case management services for catastrophic or chronic injuries/illnesses; affects providers managing Health Net members.

Policy Summary

Payermhn

PolicyCase Management

Policy CodePolicy N/A

Change TypeInformational update

Effective DateN/A

Next Review DateN/A

Key ActionScreen members who meet any listed utilization or status triggers and coordinate referrals with Health Net case managers via Case.Management.Referrals@healthnet.com or fax 800-745-6955.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2+Hospital admissions trigger

3+ER visits (same condition)

5+ER visits (multiple conditions)

800-745-6955Referral fax

Case Management Screening Criteria

inv-01: Screening Criteria

Screen for case management when ANY one of the following is met:

Screening triggers

Utilization: multiple hospital admissions: Members with multiple admissions (two or more hospitalizations) within six months.>= 2 admissions within six months
Utilization: ER visits or admissions for same condition: Members with multiple emergency room (ER) visits (three or more), or two hospital admissions, for the same condition within six months.>= 3 ER visits (or 2 hospital admissions) for same condition within six months
Utilization: ER visits for multiple conditions:

Policy Summary

Payermhn

PolicyCase Management

Policy CodePolicy N/A

Change TypeInformational update

Effective DateN/A

Next Review DateN/A

Key ActionScreen members who meet any listed utilization or status triggers and coordinate referrals with Health Net case managers via Case.Management.Referrals@healthnet.com or fax 800-745-6955.

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 That Trigger Screening

inv-04: Hospital admissions for screening

Threshold>= 2 hospital admissions within six months

ContextTrigger for screening members for case management services

TimeframeSix months

inv-05: ER visits for same condition for screening

Threshold>= 3 ER visits for the same condition within six months (or 2 hospital admissions for the same condition within six months)

ContextTrigger for screening members for case management services

TimeframeSix months

inv-06: ER visits for multiple conditions for screening

Threshold>= 5 ER visits for multiple conditions within six months

ContextTrigger for screening members for case management services

TimeframeSix months

What Providers Must Do / How to Refer

Denial Risk

Denial / Triage Note

No explicit denial triggers are specified in this policy. Screening for case management is indicated when the utilization or member status criteria listed below are met; absence of a listed trigger should not be interpreted as a denial condition.

No explicit denial triggers stated in this document; screening is indicated when listed utilization or status criteria are met.

Note

Referral, Contact, and Coordination

Providers should screen members who meet the stated criteria and coordinate referrals with Health Net case managers or delegated participating physician groups. Case managers work with members, caregivers, physicians and the care team to manage medically catastrophic or complex chronic cases and help achieve optimal care and coverage outcomes.

Coordinate referrals and care with Health Net case managers or delegated PPGs.
Case managers assist members, caregivers, physicians and the care team to manage complex cases.

Note

Provider Screening Criteria

Screen members for case management services when they meet any of the following criteria. If a member meets these criteria, refer to Health Net Case Management by email or fax as shown below.

Two or more hospitalizations within six months.
Three or more ER visits, or two hospital admissions, for the same condition within six months.
Five or more ER visits for multiple conditions within six months.
Members eligible for public health programs.
Members accepted into clinical trials.
Pregnant members with high-risk conditions.
Members identified via the health risk questionnaire process.
Members referred from Health Net's Case Management Department.

Note

How to Refer / Contact Case Management

To refer or request assistance from Case Management, contact Health Net Case Management: Email: Case.Management.Referrals@healthnet.com Fax: 800-745-6955. Use these contacts for referrals from providers and delegated PPGs.

Program Background

Case management is offered for members who are experiencing catastrophic and chronic injuries or illnesses. Case managers — either Health Net case managers or delegated participating physician groups (PPGs) — work with members, caregivers, physicians and other care team members to coordinate care and optimize coverage benefits for the member. Providers should screen patients against the listed utilization, status and program triggers to identify candidates for case management and contact the Case Management Department via email at Case.Management.Referrals@healthnet.com or fax at 800‑745‑6955 for additional information or referral.

OpenPayer

Case Management

Case Management Screening Criteria

Utilization Thresholds That Trigger Screening

What Providers Must Do / How to Refer

Program Background

Key Definitions