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Suspension of Coverage Letter

Provider Type

  • Participating Physician Groups (PPG)

Members' eligibility is suspended if they are delinquent on premium payments during months two and three of the three-month federal premium delinquency grace period. Health Net or delegated CommunityCare participating physician groups (PPGs) must customize the templates, as described below, and send these letters to applicable providers no later than day 15 of months two and three of the grace period. The letter templates notify providers of a member's delinquent status upon Health Net's receipt of a claim for a delinquent member.

Provider Notice of Suspension Letter Descriptions

The following five letters pertain to Health Net delegated CommunityCare plans:

  • Type 1-APTC Pend Claim letter (PDF) - Informs providers of a member's premium delinquency status. Delegated PPGs must send this notice to their contracting providers upon receipt of a claim for service dates occurring in months two and three of the premium delinquency grace period.
  • Type 3A-APTC Primary Care Physician (PCP)/PPG letter (PDF) - Informs assigned PCPs of a member's premium delinquency status and notifies providers that coverage is suspended until the member's premium is paid in full.
  • Type 3B-APTC Claims Look-Back letter (PDF) - Informs providers of a member's premium delinquency status. Delegated providers must send the letter to participating and nonparticipating providers who submitted claims for the APTC enrollee during the two months prior to the enrollee's federal grace period.
  • Type 4-APTC Authorization Rescind letter (PDF) - Informs providers that unless certain services have been rendered, Health Net or the delegated PPG rescinds authorization for coverage of the service, effective immediately.
  • Type 5-APTC Inpatient Authorization Rescind letter (PDF) - Reminds members that their eligibility is suspended and informs them that the request for authorization of additional inpatient days is denied until outstanding premiums are paid in full, effective immediately.
Last Updated: 10/30/2019