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. Terminal illness is defined as a member having a life expectancy of one year or less as stated in writing by their attending physician or surgeon, or the member has an incurable or irreversible condition that has a high probability of death within one year.
For an initial review of a request for services, Health Net does the following:
- Gives 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.