Continued Access to Non-Participating Providers for SPD Members
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
Health Net requires all subcontracting health plans, delegated participating physician groups (PPGs) and capitated hospitals to adhere to the Procedures for SPD Members Requesting Services from Non-Participating Providers (see section below). Health Net subcontractors must arrange for medically necessary services for newly enrolled Seniors and Persons with Disabilities (SPD) members to be provided by non-participating providers when the SPD member requests such services. This applies to Medi-Cal members enrolled in Health Net's Medi-Cal plan directly from the Medi-Cal FFS program beginning June 1, 2011, and who are in one of the following aid codes:
Disabled (Medi-Cal only - Not Medicare eligible): 20, 24, 26, 2E, 2H, 36, 60, 64, 66, 6A, 6C, 6E, 6G, 6H, 6J, 6N, 6P, 6V
Aged (Medi-Cal only - Not Medicare eligible): 10, 14, 16, 1E, 1H
SPD members who request continued access to existing non-participating providers may be treated by the non-participating provider for medically necessary services for up to 12 months from the date of the member's enrollment in Health Net, if there are no quality-of-care issues involving the provider. If an SPD member agrees to transition to a participating provider earlier than the 12-month transition period, the PPG is encouraged to work with the member and transition him or her to a participating provider.
Health Net's subcontractors - a Medi-Cal capitated PPG, a Medi-Cal capitated hospital or Molina Healthcare - must pay non-participating providers providing covered services for SPD members under the terms and conditions of the guidelines and requirements in the above procedure at the higher of the subcontractor's Medi-Cal contracting rate, or the Medi-Cal fee-for-service (FFS) provider rate. Health Net's subcontractors may require non-participating providers to agree in writing to contractual terms and conditions, including, but not limited to, prior authorization, hospital privileging, utilization review, case management, and quality performance requirements.
Additional Terms and Conditions of Coverage
Following are additional terms and conditions of coverage for continuation of care by a non-participating provider:
- A newly enrolled SPD member has an ongoing relationship with the requested provider
- The requested provider was not terminated from participation with Health Net or its subcontractor for a medical discipline reason, fraud or crime
- The requested provider is not excluded, suspended or terminated from participation in the Medicare or Medi-Cal and Medicaid programs
- Services to be rendered by the provider are covered services
Health Net Responsibilities
Health Net follows these steps to notify subcontractors of newly enrolled Seniors and Persons with Disabilities (SPD) members who request to continue to obtain medically necessary care and services from a non-participating provider during their 12-month transition period following enrollment with Health Net:
- The SPD member or the member's representative calls or writes Health Net's Medi-Cal Member Services Department, Community Health Plan of Imperial Valley Member Services Department or CalViva Health Member Services Department to request that the SPD member continue to be treated by a non-participating provider.
- The Plan's Medi-Cal Member Services Department verifies, to the extent possible, with the SPD member that he or she has an ongoing relationship with the requested provider and forwards the completed Transition of Care/Continuation of Care Request Form for response to either:
- Health Net's Medi-Cal Health Care Services Department.
- Molina Healthcare's medical director when the SPD member is assigned to Molina.
For the purposes of these guidelines and requirements, references to medical director are meant to include the member's designated case manager.
- The Health Net Medi-Cal Health Care Services Department representative reviews the fee-for-service (FFS) utilization data provided by Department of Health Care Services (DHCS) to verify claims were paid under the FFS Medi-Cal program to the requested non-participating provider. If the requested non-participating provider does not appear in the FFS utilization data, the representative contacts the requested provider to obtain visit history for the SPD member. The representative then forwards the completed form to the member's assigned PPG medical director.
Subcontractor Responsibilities
- Upon receipt of the completed Transition of Care/Continuation of Care Request Form, the applicable PPG or Molina medical director or designee determines whether the SPD member qualifies for coverage of continuation of care by the non-participating provider. This includes confirming that there are no quality-of-care issues involving the non-participating provider and whether the non-participating provider is willing to provide the continuation of care at the higher of the subcontractor's Medi-Cal contracting rate or the Medi-Cal FFS provider rates. If the non-participating provider does not agree to these or other permissible terms, then Health Net is not required to provide the new SPD member with continued access to covered services offered by the non-participating provider.
- If the applicable PPG or Molina medical director or designee determines that the SPD member does not qualify for continued access to a non-participating provider in accordance with this policy, the medical director or designee:
- Arranges for a participating provider to provide for the SPD member's care.
- Informs the SPD member of the determination in a timely manner appropriate for the SPD member's clinical condition, not to exceed five business of the member's request.
- If the applicable PPG or Molina medical director or designee determines that the SPD member qualifies for continued access to a non-participating provider in accordance with this policy, and the non-participating provider agrees on a rate and to comply with any of the subcontractor's other contractual requirements, the medical director or designee:
- Authorizes coverage for continuation of care by the non-participating provider.
- Informs the SPD member of the determination in a timely manner appropriate for the SPD member's clinical condition, not to exceed five business of the member's request.
- Subcontractors are required to track the number of continuation of care requests that are approved and the number that are denied, along with the reason that they are denied.