Termination of Provider Services
- Participating Physician Groups (PPG)
A termination of service is the discharge of a member from covered provider services, or discontinuation of covered provider services, when the member has been authorized by Health Net or the participating physician group (PPG) to receive an ongoing course of treatment from that provider, including home health agencies (HHAs), skilled nursing facilities (SNFs) and comprehensive outpatient rehabilitation facilities (CORFs). Termination includes cessation of coverage at the end of a course of treatment pre-authorized in a discrete increment, regardless of whether the member agrees that such services should end.
Advance Written Notification of Termination
Prior to any termination of service, the provider of service must deliver a valid written notice to the member of the decision to terminate the services. The provider must use the standardized notice, and follow specific procedures regarding timing and content of the notice. The standardized termination notice must include:
- The date coverage of services ends
- The date the member's financial liability for continued services begins
- A description of the member's right to a fast-track appeal, including information on how to contact the independent review entity (IRE), a member's right to submit evidence showing that services should continue, and the availability of Health Net's Medicare appeal procedures if the member fails to meet the deadline for a fast-track IRE appeal
- The member's right to receive detailed information about the termination notice and all documents sent by the provider to the IRE
The Notice of Medicare Non-Coverage (NOMNC) is issued at least two days in advance of the ending of approved coverage for SNF, HHA or CORF services.
The Detailed Explanation of Non-Coverage (DENC) is issued when the member does not agree that covered services should end. The member may appeal by requesting an expedited appeal review of the case by the Quality Improvement Organization (QIO). Health Net or its delegated PPG must furnish the DENC explaining why the services are no longer necessary or covered on the day the QIO notifies the plan of the member's expedited appeal.
Providers may download the Centers for Medicare and Medicaid Services (CMS)-approved Health Net Medicare Advantage templates from the Industry Collaboration Effort (ICE) website at www.iceforhealth.org.