Organization Determinations
Provider Type
- Participating Physician Groups (PPG)
When a Health Net member, the member's physician or the member's authorized representative has made a request for a service, Health Net and its delegated participating physician groups (PPGs) must notify the member of its determination as expeditiously as the member's health condition requires, but no later than 14 calendar days after the date the organization receives the request for a standard organization determination.
Health Net or PPGs may extend the time frame up to 14 calendar days. This extension is allowed to occur if the member requests the extension or if the organization justifies a need for additional information and documents how the delay is in the interest of the member (for example, the receipt of additional medical evidence from non-participating providers may change the decision to deny). When Health Net or a PPG grants itself an extension to the deadline, it must notify the member, in writing, of the reasons for the delay, and inform the member of the right to file a grievance if they disagree with the Medicare health plan's decision to grant an extension. Health Net or PPGs must notify the member, in writing, of the determination as expeditiously as the member's health condition requires, but no later than the expiration of any extension that occurs.
Pre-Service Organization Determination
A member, or a participating provider acting on behalf of the member, has the right to request a pre-service organization determination if there is a question as to whether an item or service is covered by Health Net. If Health Net denies the member or the participating provider's request for coverage as part of the organization determination process, Health Net provides the member and provider, as applicable with the standardized Notice of Denial of Medical Coverage.
Organization Determination Review
If Health Net or a PPG expects to issue a partially or fully adverse medical necessity decision based on the initial review of the request, the organization determination must be reviewed by a physician or other appropriate health care professional with sufficient medical or other expertise, including knowledge of Medicare coverage criteria (from the National Coverage Determination, Local Coverage Determination and National Coverage Determination Manual), before issuing the organization determination. The physician or other health care professional must have a current and unrestricted license to practice within the scope of his or her profession in the United States. Note: The physician or other health care professional must remember to apply the prudent layperson standard (42 CFR 422.113(b)(1)) when making organization determinations regarding emergency services.
Notice Requirements for Standard Organization Determination
If Health Net or a PPG denies services or payments, in whole or in part, or discontinues or reduces a previously authorized ongoing course of treatment, it must give the member a written notice of its determination.
Health Net or the PPG must provide notice using the most efficient manner of delivery to ensure the member receives the notice in time to act (for example, fax, hand-delivery or mail). If the member has a representative, the representative must be given a copy of the notice. The written notice of determination may be a separate document from any plan-generated claims statement to the member or provider. Such other generated statements may include Explanations of Benefits (EOBs), detailing what the plan has paid on the member's behalf, or the member's liability for payment.
If Health Net or a PPG fails to provide the member with timely notice of an organization determination, this failure itself constitutes an adverse organization determination and may be appealed.
Health Net or the PPG must use the approved notice language (such as the Integrated Denial Notification - Notice of Denial of Medical Coverage (IDN-NDMC) and Integrated Denial Notification - Notice of Denial of Payment (IDN-NDP)). If Health Net or the PPG uses its existing system-generated notification (such as the EOB) as its written notice of determination regarding payment denials, the plan or the PPG must ensure that the EOB contains the OMB-approved language of the IDN-NDP verbatim and in its entirety, and meets the content requirements listed in the IDN-NDP's form instructions.
The standardized denial notice forms have been written in a manner that is understandable to the member and must provide:
- The specific reason for the denial that takes into account the member's presenting medical condition, disabilities and special language requirements, if any
- Information regarding the member's right to a standard or expedited reconsideration and the right to appoint a representative to file an appeal on the member's behalf (as mandated by 42 CFR 422.570 and 422.566(b)(3))
- For service denials (using the IDN-NDMC), a description of both the standard and expedited reconsideration processes and time frames, including conditions for obtaining an expedited reconsideration, and the other elements of the appeals process;
- For payment denials (using the IDN-NDP), a description of the standard reconsideration process and time frames, and the rest of the appeals process
- The member's right to submit additional evidence in writing or in person
Examples of Unacceptable/Acceptable Denial Rationale
Health Net and the PPG must provide enough information for the member to understand the reason for the request denial.
Below is an example of unacceptable denial rationale because it is not specific enough or does not provide the background necessary to indicate why rehabilitation services are no longer necessary:
- You required skilled rehabilitation services - Physical therapy for mobility plus gait, including ADLs, swallowing evaluation and speech therapy - are no longer needed on a daily basis
The denial rationale must be specific to each individual case and written in a manner that a member can understand.
Below are examples of language that are acceptable because they provide detail sufficient to guide the member on any further action, if necessary:
- The case file indicated that while Jane Doe was making progress in her therapy programs, her condition had stabilized and further daily skilled services were no longer indicated. The physical therapy notes indicate that she reached her maximum potential in therapy. She had progressed to minimum assistance for bed mobility, moderate assistance with transfers, and was ambulating to 100 feet with a walker. The speech therapist noted that her speech was much improved by 6/5/2015, and that her private caregiver had been instructed on safe swallowing procedures and will continue with feeding responsibilities.
- Home health care must meet Medicare guidelines, which require that you are confined to your home. You are not homebound and consequently the home health services requested are not payable by Medicare or the Medicare health plan.
- Golf carts do not qualify as durable medical equipment (DME) as defined under Medicare guidelines. Medicare defines DME as an item determined to be necessary on the basis of a medical or physical condition, is used in the home or an institutional setting, and meets Medicare's safety requirements. A golf cart does not meet these requirements and is not payable by Medicare or Health Net.
In cases involving emergency services, Health Net and the PPG must apply the prudent layperson standard when making the organization determination, as described under 42 C.F.R. 422.113(b)(1).
Notice Requirements for Non-Participating Providers
If Health Net or a PPG denies a request for payment from a non-participating provider, Health Net or the PPG must notify the non-participating provider of the specific reason for the denial and provide a description of the appeals process. Plans must deliver either a remittance advice or similar notification that includes the following information:
- Non-participating providers have the right to request a reconsideration of the plan's denial of payment.
- Non-participating providers have 60 calendar days from the remittance notification date to file the reconsideration.
- Non-participating providers must include a signed Waiver of Liability form holding the member harmless regardless of the outcome of the appeal (include either the form or a link to the form).
- Non-participating providers should include documentation, such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider's argument for reimbursement.
- Non-participating providers must mail the reconsideration to the plan (provide appropriate plan address).
Failure to Provide Timely Notice
If Health Net or the PPG fails to provide the member with timely notice of an organization determination, this failure itself constitutes an adverse organization determination and may be appealed.