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Provider Quality Improvement

Building Trusted Partnerships with Providers and Members

Welcome to the Quality Improvement (QI) Corner! A major focus of the QI Program is to continuously improve the quality of care and service provided to our members. In an effort to promote and encourage utilization of Health Net's QI Program, providers can access the QI Corner, a centralized location for current best practices. The QI Corner includes tools and resources that will help you improve:

  • Access to care
  • Coordination of care
  • Communication between provider and patient
  • Patient safety
  • Depression management

Health Net encourages you to utilize the tools that are right for your office or organization. Please remember that small steps towards improving quality can make a huge difference! For questions about the QI Corner and its content, please contact us.

Quality Improvement & Health Equity Program Reports

  • Quality Improvement (QI) and Health Equity Annual Reports
  • Quality Improvement and Health Equity Committee Activities
  • Community Reinvestment Plan
  • Community Reinvestment Report
  • Member Satisfaction Survey Results (Consumer Assessment of Healthcare Providers and Systems (CAHPS))

Featured Topics

Provider Resources

Provider Education

Regulatory Information

Health Net wants members to experience the highest quality of care from the physicians and other providers in its network. To that goal, Health Net recognizes the importance of collaborating with, and supporting, providers in their efforts to improve member's health and meet Medicare's quality standards for our Medicare Advantage (MA) plans.

Quality improvement is a major initiative for the Centers for Medicare and Medicaid Services (CMS). CMS uses the Medicare Five - Star Quality Rating System to monitor the performance of MA health plans to ensure they meet quality standards. For MA members, the ratings provide a tool to compare the quality of care and customer service offered by different MA plans. Providers have a direct impact on over 60 percent of the measures that are used for these ratings.

The rating for the quality of medical services includes multiple measures that fall into the following five categories.

  • Staying healthy – Measures whether members received various screening tests, vaccines and other checkups that help them stay healthy.
  • Managing chronic conditions – Measures how often members with different conditions received certain tests and treatments that help them manage their condition.
  • Member experience with the health plan – Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan's performance – Measures how often Medicare found problems with the plan and how often members had problems with the plan. Also measures the plan's performance over time.
  • Health plan customer service – Measures how well the plan handles member appeals.

Provider's participation and assistance in providing the highest quality of care to Health Net members is vital to meeting CMS' expectations in the delivery of care to MA members. In an effort to accomplish this goal and meet CMS standards, Health Net has developed tools for provider's use. Please click on the links in the sections below to access these tools.

For up-to-date Provider Tip Sheets refer to HEDIS Measures & Billing Codes.

Maintaining continuity in patients' medical care is critical following discharge from the hospital to ensure successful recovery. Poor coordination of care across settings can result in costly, potentially harmful, and often avoidable re-hospitalizations. Poor care transition, failures in communication between providers, lack of patient and family involvement and few standardized tools and processes can all contribute to adverse events or avoidable readmissions. Evidence suggests improving core discharge planning and transition processes out of the hospital may reduce the rate of avoidable re hospitalizations.

The materials in this toolbox outlines best practices and provides easy-to-use tools and resources to help hospitals improve or redesign care processes to reduce avoidable hospital readmissions that occur within 30 days of discharge.

Discharge Planning

Patient Engagement

Tools and Links

Bone-Density Testing

Bone-density testing typically should start at age 65 and be administered every two years or more frequently as determined by the physician. According to National Osteoporosis Foundation guidelines, there are several groups of people who should consider bone-density testing:

  • All postmenopausal women under age 65 who have risk factors for osteoporosis
  • Postmenopausal women with fractures. This is not mandatory because treatment may well be started regardless of bone density
  • Women with medical conditions associated with osteoporosis. A primary care physician can assess the patient's risk profile for osteoporosis
  • Women whose decisions to use medication might be aided by bone-density testing

Approximately one third of community dwelling adults over the age of 65 report experiencing a fall in the past 12 months. Many of these falls result in significant injuries such as fractures and head injuries, reduced quality of life and mortality. In addition, the annual direct and indirect costs of fall injuries are expected to reach 54.9 billion by 2020.

Multiple studies have validated that interventions such as encouraging physical exercise, performing medication reviews and correcting environmental hazards can have a positive impact on fall management. The American Geriatric Society has published the Clinical Practice Guideline: Prevention of Falls in Older Persons with recommendations for screening, assessment and interventions. This and additional materials on Fall Risk Management including patient education brochures from the CDC and National Council on Aging (NCOA) are provided as a resource for providers. Please use the presentation and materials below to learn more about this important public health issue and incorporate fall prevention into standard office practice.

Additional Resources

The Department of Health Care Services (DHCS) requires all new Medi-Cal members complete their comprehensive Initial Health Appointment with a provider within the primary care setting within 120 days from plan enrollment. The Initial Health Appointment (IHA) can be completed by a primary care physician (PCP), nurse practitioner, certified nurse midwife, or physician assistant. At a minimum, it must include:

  • Physical, social, or mental health histories.
  • Preventive care services.
  • Physical examination.

The IHA is required by DHCS for all newly enrolled patients, including those with disabilities. Providers must follow DHCS requirements for completing the IHA, in accordance with DHCS Plan Letters 08-003 and 13-001.

Additional information on IHA Requirements for Medi-Cal Patients

Provider News:

The Department of Health Care Services (DHCS) requires that all providers who conduct periodic health assessments on Medi-Cal children provide the following:

  • Verbal or written anticipatory guidance to child's legal parent or guardian of the harmful effects of lead exposure for children starting at ages six months to 72 months (6 years). At a minimum, the information should include that:
    • Children can be harmed by lead exposure from old or chipping lead-based paint and dust.
    • Children that begin to crawl until 72 months of age, are particularly at risk.
  • Blood lead level testing (finger stick or venous blood draw) on children:
    • At 12 months and 24 months of age.
    • If child between ages 12-24 months have no record of lead testing.
    • If child between ages 24-72 months is missing a lead test at 24 months or after.
    • When requested by child's parent or guardian.
    • When provider conducting Periodic Health Assessment (PHA) for child 12-72 months is aware of increased risk of lead exposure/poisoning due to changes in child's circumstances.

Providers must follow the California Department of Public Health Guidelines (PDF) for interpreting blood lead levels and follow-up activities for elevated blood lead levels.

  • Screening for elevated blood levels can be conducted by finger stick test or via venous blood draw.
  • Confirming or retesting of blood lead levels should be conducted through the venous blood test.

Tools to help you complete lead screenings

Health Net provides the following tools to help providers identify children who need a lead test.

If you are not receiving your care gap reports, reach out to your provider representative for information on obtaining or how to review these reports.

Submit codes as evidence of lead testing

Providers can use the following codes for submitting claims/encounters as evidence for lead testing:

Encounter Description Codes1
Venous blood collection CPT 36415
Capillary blood collection CPT 36416
Lead test CPT 83655
Abnormal lead level in blood ICD-10 R78.71
Toxic effect of lead and its compounds, accidental (unintentional), initial encounter ICD-10 T56.0X1A
Toxic effect of lead and its compounds, accidental (unintentional), subsequent encounter ICD-10 T56.0X1D
Toxic effect of lead and its compounds, accidental (unintentional), sequela ICD-10 T56.0X1S
Encounter for routine child health examination without abnormal findings ICD-10 Z00.129
Encounter for screening for disorder due to exposure to contaminants ICD-10 Z13.88
Contact with and (suspected) exposure to lead ICD-10 Z77.011

Providers and labs must report all lead test results to the Childhood Lead Poisoning Prevention Branch (CLPPB). Contact EBLRSupport@cdph.ca.gov.

Exceptions to providing a lead screening

Providers are not required to perform lead screening if:

  • Legal parent/guardian refuses the lead screening and signs a voluntary refusal statement.
  • In provider's professional judgement, lead testing poses greater risk for child than lead poisoning.

Providers must document reasons for not providing the lead screening or not obtaining the voluntary refusal statement in the child's medical record.

Education you can share with your patients

Additional information on Lead Screening Requirements for Medi-Cal Patients

Health Net Provider News

Department of Health Care Services: APL 20-016 Blood Lead Screening of Young Children – English (PDF)

Last Updated: 07/01/2024