20-494 View Medical Necessity Guidelines for Paclitaxel Online in Four Steps or Less
Date: 08/03/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Refer to the payment integrity policy for details
Health Net has implemented a payment integrity policy that describes medical necessity guidelines for paclitaxel (Abraxane®).
Refer to the table below of this update for a description of the policy.
Health Net’s reimbursement to contracted providers for covered services is based on specific negotiated contract provisions supplemented by the contents of disclosed and consistent fee schedules, payment policies and coding methodologies.
Access new policies simply
Use one of the two options below to view policies in the Provider Library.
Option 1 – Log on to the provider website
If you are serving members enrolled in... | Go to... |
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Option 2 – Go directly to the Provider Library
1. Go to providerlibrary.healthnetcalifornia.com.
2. Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.
Policy chart
The following chart lists the policy number, policy name, a description of the policy, applicable providers and applicable lines of business.
Policy number | Policy name | Description of policy | Providers | Lines of business |
CP.PHAR.176 | Paclitaxel, protein-bound (Abraxane) | This policy advises that Abraxane is medically necessary when the criteria described in the policy are met. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. Payment for claims submitted outside of these medically necessary guidelines will be denied. Please see the CPT and ICD-10 coding guidelines documented in the policy. The applicable claims edit will be applied to claims for dates of service after February 14, 2020. | Physicians, participating physician groups, hospitals and ancillary providers | Commercial*, Medicare, Medi-Cal |
*Commercial includes HMO, POS, HSP, PPO, EPO and products offered through Covered California.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on Health Net’s provider website as listed in the right-hand column.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email at provider_services@healthnet.com within 60 days, by telephone or through the Health Net provider website as listed Below.
Line of Business | Telephone Number | Provider Portal |
EnhancedCare PPO (IFP) | 1-844-463-8188 | |
EnhancedCare PPO (SBG) | 1-844-463-8188 | provider.healthnet.com |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider.healthnet.com |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | |
Medicare (individual) | 1-800-929-9224 | |
Medicare (employer group) | 1-800-929-9224 | provider.healthnet.com |
Medi-Cal | 1-800-675-6110 | provider.healthnet.com |