Monitoring Provider Exclusions

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

The Centers for Medicare & Medicaid Services (CMS) and the California Department of Health Care Services (DHCS) both require contractors, their subcontractors and other delegated entities to monitor federal and state exclusions lists. The parties or entities on these lists are excluded from various activities, including rendering services to Medicaid enrollees (unless in the case of an emergency, as stated in 42 CFR §1001.1901), and employing or contracting with excluded parties to provide services to Medicaid enrollees. Health Net requires that its participating physician groups (PPGs), hospitals, ancillary providers, and physicians frequently monitor federal and state exclusion lists.

Monitoring for Excluded Parties

The names of parties that have been excluded from participation in federal health care programs are published in the Office of the Inspector General U.S. Department of Health and Human Services (OIG-HHS) List of Excluded Individuals and Entities (LEIE), CMS Preclusion List,  and on the General Services Administration's (GSA) Exclusions Extract Data Package (EEDP) (or Excluded Parties List System (EPLS), which was replaced by the EEDP), as referenced through the System for Award Management (SAM) website. In addition, Medi-Cal excluded providers are listed in the Medi-Cal Suspended and Ineligible Provider List (SIPL) available on the DHCS Medi-Cal website > Resources > References > Suspended & Ineligible Provider List or Sandlanding.

Providers on the SIPL will be terminated from all products, federal and non-federal.

Medicaid managed care programs, their subcontractors and other delegated entities must abide by the regulations documented in the Social Security Act 1862(e)(1)(B), 42 CFR §422.503(b)(4)(vi)(F), 422.752(a)(8), and 1001.1901, and California Welfare and Institutions Code sections 14043.6 and 14123. Additional regulations that require sponsors to include CMS requirements in their contracts, as well as monitor their subcontractors and other delegated entities, are available in 42 CFR §422.504(i)(4)(B)(v).

Health Net and Provider Responsibilities

Health Net is required to monitor federal and state exclusion lists to ensure that Health Net is not hiring, contracting or paying excluded parties or entities for services rendered to enrollees in Health Net's Medi-Cal plans. Medicaid managed care entities, their subcontractors and other delegated entities must check the LEIE, CMS Preclusion List, and EEDP federal and SIPL state exclusion lists prior to hiring or contracting with any new employee, temporary employee, volunteer, consultant, governing body member, subcontractor, or other delegated entity for Medicaid-related activities. Medicaid managed care entities, their subcontractors and other delegated entities must frequently monitor these lists at least monthly to ensure parties or entities that were previously screened have not become excluded later.

LEIE

The OIG-HHS imposes exclusions under the authority of sections 1128 and 1156 of the Social Security Act. A list of all exclusions and their statutory authority is available on the Exclusion Authority website at https://oig.hhs.gov/exclusions.

The current LEIE is available on the OIG-HHS website. Frequently asked questions (FAQs) and additional information about the LEIE is available at OIG.

Providers on the OIG list will be terminated from all products, federal and non-federal.

EEDP

The GSA's EEDP is a government-wide compilation of various federal agency exclusions and replaces the Excluded Parties List System (EPLS). Exclusions contained in the EEDP are governed by each agency's regulatory or legal authority. The EEDP also includes parties and entities from other federal exclusion databases. All parties or entities listed on the EEDP are subject to exclusion from Medicaid participation. The current EEDP is available on the SAM website.

Providers on the EEDP list will be terminated from all products, federal and non-federal.

SIPL

The SIPL is published by DHCS to identify suspended and otherwise ineligible providers. It is updated monthly and available on the DHCS Medi-Cal website > Resources > References > Suspended & Ineligible Provider List or Sandlanding. Additional information about the list is located in the Medi-Cal Suspended and Ineligible Provider List introduction.

Providers on the SIPL will be terminated from all products, federal and non-federal.

CMS Preclusion List

The CMS Preclusion List is published by CMS to identify precluded providers. It is updated monthly and available on the Healthnet.com site, after logging on, under the regulatory section.

Providers on the CMS Preclusion List will be terminated from all products, federal and non-federal.

CLAIMS PAYMENT FOR EXCLUDED PARTIES

Health Net, its PPGs, vendors, hospitals, and ancillary providers cannot pay participating and nonparticipating parties or entities included on these lists for any services using federal funds, except for emergency services provided by excluded providers under certain circumstances, see 42 CFR §1001.1901. Providers contracting with Health Net must have a documented process in place to ensure compliance with these guidelines, and notify enrollees who obtain services from excluded parties and make claims payments as allowed under these exceptions. This documentation is subject to audit upon request from Health Net or CMS.