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Provider Participation Agreement

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)

The Provider Participation Agreement (PPA) between participating physician groups (PPGs) and Health Net complies with the changes made to the Balanced Budget Act of 1997 (BBA) and Operational Policy Letter 98.077 (OPL #77). This includes the addition of sections 1851 through 1859 to the Social Security Act to establish Part C of the Medicare program, known as the Medicare Advantage (MA) program. The BBA amended federal law stating that certain requirements must be included in agreements between MA Organizations (MAOs) and their PPGs.

Health Net of California is an MAO as defined by the BBA, and its PPGs must comply with Medicare laws, regulations, and the Centers for Medicare and Medicaid Services (CMS) instructions. Additionally, PPGs must comply with the MAO's operational procedures as described in the Medicare Advantage Provider Operations Manual. In all instances where the Medicare-required provisions of the downstream provider contract, whether in the MA addendum or otherwise, differ from the PPA and/or the MA Provider Operations Manual, the Medicare-required provisions of the downstream provider contract take precedence.

Downstream contracts are contracts that provider organizations have with other providers.

All contracts that health plans have with their participating providers and all downstream contracts issued by participating providers must be in compliance with the Centers for Medicare & Medicaid Services (CMS) requirements of Medicare Managed Care Manual - Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements. CMS continues to audit provider organization and hospital compliance with these downstream contracting requirements.

Health Net of California, the participating physician group (PPG), and downstream participating providers must comply with Medicare laws, regulations, and CMS instructions. Additionally, participating providers must comply with the MA organization's (MAO's) operational procedures as described in the Medicare Advantage Provider Operations Manual. In all instances where the Medicare-required provisions of the downstream provider contract, whether in the MA addendum or otherwise, differ from the Provider Participation Agreement (PPA) and/or the MA Provider Operations Manual, the Medicare-required provisions of the downstream provider contract take precedence.

Last Updated: 10/30/2019