22-514 Monitor Suspended and Excluded Lists to Prevent Getting Terminated
Date: 06/30/22
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.
Use the provided list to determine line of business impact
In accordance with state and federal rules, Health Net is prohibited from paying providers for items or services they furnish, order, or prescribe if the provider is excluded from participation in federally funded health care programs.
Effective Sept. 6, 2022, providers included on the Office of the Inspector General (OIG) List of Excluded Individuals/Entities (LEIE), Suspended and Ineligible Provider Listing (SIPL), and Centers for Medicare and Medicaid Services (CMS) Preclusion List will be terminated by Health Net for all products.
Providers on the Restricted Provider Database (RPD) will not be affected by this change and will continue to be excluded for the Medi-Cal product only.
Review the chart below to see how the lists might affect you.
Review the provider exclusions list
CMS and the Department of Health Care Services (DHCS) both require contractors, their subcontractors, and other delegated entities to review federal and state exclusions lists at initial contracting and on a regular basis; at least monthly.
These lists (below) include providers excluded from activities such as:
- Rendering services to enrollees.
- Employment or contracting to provide services to enrollees.
List name | Overview |
|---|---|
OIG LEIE | Provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other federal health care programs. |
SIPL | Suspended and otherwise ineligible providers prohibited from participation in the Medi-Cal program. |
RPD | Providers placed under a Medi-Cal payment suspension while under investigation based upon a credible allegation of fraud. |
CMS Preclusion List | Providers precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries. |
How is the provider affected?
If the provider is on this list… | The provider will be terminated from these lines of business | Federal entity | Site |
|---|---|---|---|
OIG LEIE | All lines of business | Medicare and Medi-Cal | |
SIPL | All lines of business | Medi-Cal | |
RPD | Medi-Cal line of business only | Medi-Cal |
|
CMS Preclusion List | All lines of business | Medicare | Distributed to providers by Wellcare by Health Net (Health Net*)
|
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 after logging in to Health Net’s provider website > Provider Library under Quick Links, or go directly to provider library.
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center by email within 60 days.