Denial of Investigational or Experimental Treatment for a Terminal Illness

In accordance with standards established by the Department of Managed Health Care (DMHC), Health Net has five calendar days to respond to member requests for investigational or experimental treatment for a terminal illness. Health Net is required to review all requests for these procedures and, in the case of a denial, is responsible for issuing the denial letter. Participating physician groups (PPGs) are required to notify Health Net immediately of member requests or proposed services for expedited investigational or experimental treatment for a terminal illness.

Terminal illness is defined as a member having a life expectancy of six months or less as stated in writing by his or her attending physician or surgeon, or the member has an incurable or irreversible condition that has a high probability of death within one year.

PPGs must immediately forward all pertinent documentation for investigational or experimental treatment for a terminal illness via fax to Health Net's Continuity and Coordination of Care Department. PPGs must not direct members to contact Health Net for approval of these services. It is the PPG's responsibility to contact and provide Health Net with pertinent information and documentation.

Health Net's Coordination of Care Department has a dedicated fax number and address to receive PPGs' requests for investigational or experimental treatment for terminal illnesses to ensure timely processing. For an initial review of a request for services, Health Net does the following:

• Give written notice to the member within five business days of the decision. The notice must state the medical and scientific reasons for the denial and state an alternative treatment that Health Net does cover. It also includes Health Net's appeals and grievance procedures or complaint form, or both, which advise the member of the right to request a conference to discuss the denial
• If the member requests a conference, the conference is held by a person with the authority to uphold the denial or approve coverage. The conference is held within 30 calendar days from the receipt of Health Net's decision, unless the treating participating physician determines the effectiveness of the proposed or alternative treatment would be reduced if not provided at the earliest possible date. In that case, the conference must be held within five business days. The member is entitled to have a designee attend. This could be an attorney or, in the event the member is a minor, a parent or guardian