Denial of Investigational or Experimental Treatment for a Terminal Illness
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
In accordance with Centers for Medicare & Medicaid Services (CMS) guidelines, providers must follow the process for review of 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. Refer to the Health Industry Collaboration Effort (ICE) website at www.iceforhealth.org/home.asp to view the denial letter template located under Approved ICE documents.
Participating physician groups (PPGs) are required to notify Health Net immediately of member requests or proposed services for expedited investigational or experimental treatment for a terminal illness.
Definition of a Terminal Illness
A terminal illness is defined as an incurable or irreversible condition that has a high probability of causing death within two years.
Definition of an Expedited Request
An expedited request is defined as a time-sensitive situation where a delay in treatment or an adverse decision could seriously jeopardize the life or health of the member or their ability to regain maximum function. This includes severe pain or potential loss of life, limb or major bodily function.
PPG Responsibilities
- PPGs must immediately forward all pertinent documentation for investigational or experimental treatment for a terminal illness via fax to Health Net's Continuity and Coordination of Care Department.
- PPGs must not direct members to contact Health Net for approval of these services. It is the responsibility of the PPG to contact and provide Health Net with pertinent information and documentation.
Health Net follows the denial letter process and Health Net's Continuity and Coordination of Care Department has a dedicated fax number and address to receive PPGs' submissions of these cases to ensure timely processing.