Special Risk Reinsurance
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
The following applies to capitated participating physician groups (PPGs) or hospitals that have purchased special-risk reinsurance from Health Net, as indicated in the PPG and hospital Provider Participation Agreement (PPA). Unless otherwise provided in the PPG or hospital's PPA, the terms of the special-risk reinsurance program are described below.
Special-risk reinsurance limits PPG or hospital liability for some of the expenses incurred for claims of professional, institutional and pharmacy providers for services they provide to members with AIDS. When purchased by the PPG or hospital, Health Net pays the PPG's or hospital costs attributable to these services.
Reinsurance amounts for HMO members are deducted from the PPG's or hospital's monthly capitation, as set forth in the PPA. For Point of Service (POS) members, reinsurance premiums are deducted from the PPG's capitation and shared-risk budget in accordance with the terms of the PPG's PPA.
PPGs and hospitals that elect not to participate in the special-risk reinsurance program are financially responsible for paying treating providers' and facilities' claims for services related to members diagnosed with AIDS, including AIDS-related pharmacy claims, where it is their financial responsibility under the PPA Division of Financial Responsibility (DOFR). When the PPG or hospital does not participate in the special-risk reinsurance program, AIDS-related pharmacy claims that are the PPG's or hospital's respective responsibility and paid by Health Net are deducted from the PPG or hospital's monthly capitation to cover these claims.
Diagnoses Associated with AIDS
Special-risk reinsurance also covers the cost of treating members with specific diagnoses associated with AIDS, notwithstanding whether the member is positive for HIV.
Specific diagnoses include:
- Candidiasis of esophagus, trachea, bronchi, or lungs
- Cryptococcosis, extrapulmonary
- Cryptosporidiosis with diarrhea in a person older than one month
- Cytomegalovirus disease of an organ other than liver, spleen, or lymph nodes in a person older than one month
- Kaposi's sarcoma in a person under age 60
- Lymphoma of the brain (primary) in a person under age 60
- Mycobacterium avium complex/M. kansasii disease, disseminate
- Pneumocystis carinii pneumonia
- Progressive multifocal leukoencephalopathy
- Toxoplasmosis of the brain in a person older than one month
- Herpes simplex virus with an ulcer lasting longer than one month or herpes simplex virus with bronchitis, pneumonia or esophagitis in a person older than one month
Additional diagnoses associated with AIDS require a positive HIV status in order to be covered through special-risk reinsurance. These diagnoses include:
- CD4 T-lymphocyte count less than 200
- More than one episode of recurrent pneumonia in one year
- Invasive cervical cancer
- Coccidiomycosis, disseminated
- HIV encephalopathy
- Histoplasmosis, disseminated
- Isosporiasis with diarrhea in an individual older than one month
- Non-Hodgkin's lymphoma
- Tuberculosis
- Recurrent salmonella septicemia
- HIV wasting syndrome
Covered Services and Payment Determination
Special-risk reinsurance covers the cost of treating members with specific diagnoses associated with AIDS, with or without HIV positivity. Claims for members who have an HIV-positive test only, with no symptoms, are not qualified to be processed through special-risk reinsurance.
In the event that the PPG or hospital fails to receive prior authorization from Health Net for an elective AIDS-related admission or fails to notify Health Net of such an admission, Health Net has the right to deny requests for payment under the special-risk reinsurance program. The costs not covered under the special-risk reinsurance program are applied to shared-risk costs or are the PPG's or hospital's financial responsibility.
Elective AIDS Admissions
PPGs and hospitals must receive prior authorization from the Health Net Medical Management Department for an elective AIDS-related admission. PPGs and hospitals must notify Health Net's Medical Management Department in a timely manner of urgent or emergency AIDS-related admissions for members with AIDS who are receiving anti-viral home infusion treatments and members with AIDS who are receiving total parenteral nutrition. Timely notification is defined as within 24 hours of admission or initial treatment, or the next business day following an admission or initial treatment on a holiday or weekend.
Requests for Payment Submission
To request payment for AIDS-related costs through special risk reinsurance, PPGs and hospitals must submit requests for payment to the Health Net Reinsurance Claims Unit. A Health Net PPG Professional Batch form (PDF) must be completed as follows and submitted with applicable documentation:
- Special-Risk Reinsurance written at the top of the form
- CMS-1500 or UB-04 form from treating provider:
- Original copies or a very clear photocopy
- Itemized bills attached to each inpatient claim
- Itemized bills attached to each electronic claim
- Copy of the Explanation of Benefits (EOB) or payment
- Items are not highlighted
- Copies of authorization for nuclear medicine claims by treating provider
- A completed Special-Risk Pool Member Identifier Form A (PDF) for first time requests for payment in place of the member's medical records. Include date member was first diagnosed with AIDS (symptomatic HIV infection). Form must be signed by PPG staff member ensuring records review occurred and case met criteria for special-risk reinsurance program
- AIDS-related conditions specified (refer to Attachment A for a list of Centers for Disease Control and Prevention (CDC) diagnoses criteria)
- A completed Special Risk Pool Claims Submission Form B (PDF) for all subsequent requests for payment for the same member
Health Net has modified the requirements for submitting requested medical records in view of member confidentiality concerns. Health Net no longer requires regular submission of the following items, but may request them in individual cases:
- Treating provider's medical records and lab reports (for example, CD4T - Lymphocyte count and HIV test result only) for members not established in special-risk reinsurance to determine if criteria are met
- Copies of treating provider's medical records with each subsequent claim submission when diagnosis on claim does not match the criteria matrix
- List of medications prescribed by a treating provider to member. Medications should match the procedures or examination charges
PPGs and hospitals must submit all requests for payment and related records within 120 days of the date of service. Health Net denies reimbursement for claims received after 120 days of the date the service is provided, and the PPG or hospital has full responsibility for the service.
Send the claim and attachments to the Health Net Reinsurance Claims Unit.
Requests for payment are processed in accordance with Health Net's procedures and terms of the PPA. Health Net subtracts from the payment the amount due to the PPG or hospital, such as any copayments the provider of service may collect and any third-party amounts the PPG or hospital collects.