Overview

A participating provider that expands its capacity by adding new or satellite facilities or new participating physicians or other subcontracting providers must notify the plan in writing at least 90 days before the addition. According to the terms of the Provider Participation Agreement (PPA), the participating provider agrees that the plan has the right to determine whether the new or satellite facilities or the new participating physicians are acceptable to the plan.

Addition of New Physicians, Providers and Facilities

Until the plan approves new subcontracting providers (for example, primary care physicians (PCPs), specialists and ancillary providers), the providers are not allowed to provide covered services under the PPA. The plan must be notified in writing at least 90 days before the addition.

The plan is free to deny participation to any new subcontracting providers and is not obligated to state a cause or explain the denial of the addition or provide the facility, provider or subcontracting providers with any right to appeal or any other due process. The plan's decision in these cases is final and binding.

In addition, hospitals, ancillary providers and participating physician groups (PPGs) are responsible for providing the plan with copies of the standard agreements used for their subcontractors. The plan reviews these standard agreements to ensure compliance with regulatory requirements¹ and directs the facility to make any changes required in order to meet the requirements. The plan requires hospitals, ancillary providers and PPGs to send sample forms to the plan for review if they make any changes to their standard agreements or replace them with new standard agreements.

Hospitals, ancillary providers and PPGs must provide the plan with a copy of the signature page for each subcontractor. Physicians or other subcontractors must be credentialed before they are added to the plan's network. Hospitals, ancillary providers and PPGs must also provide the plan a list of the names, locations and federal tax identification numbers (TINs) of all of its participating providers.

Hospitals, ancillary providers and PPGs are responsible for informing the plan when they cease to use a specific subcontractor or when they add a new subcontractor. The plan periodically sends each hospital, ancillary provider and PPG a list of the physicians or subcontractors the plan shows as active and under contract with the participating provider. Hospitals, ancillary providers and PPGs are required to review this list and notify the plan of any additions or deletions. At least annually, hospitals, ancillary providers and PPGs must provide the plan with a list of additions, deletions and address changes, as well as a complete listing.

For PPGs only, the Active Physicians Listing is available monthly on the Health Net provider portal under Welcome. Select Provider Reports > Available Reports. This report provides PPGs a means to review and revise their records on a monthly basis and communicate physician demographic changes and terminations to the plan. Additionally, this listing is used by the Provider Network Management Department to validate PCP and specialist information with the PPG on a quarterly basis.

Hospitals, ancillary providers and PPGs must furnish Health Net copies of any participating provider contract amendments within 20 days of execution.

¹Medicare Managed Care Manual, Chapter 11, Section 100.4