23-1119 Updates to Monitor Suspended and Excluded Lists to Prevent Getting Terminated
Date: 10/17/23
Use the provided list to determine line of business impact
Effective Dec. 19, 2023, Health Net is adding the Office of Personnel Management (OPM) under the Federal Employee Health Benefit Plan (FEHBP) sanction and debarment list to the suspended and excluded list process. Providers included on this list will be terminated by Health Net for all products. This change is in accordance with state and federal rules requiring prohibition 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.
Review the chart below to see how the lists might affect you.
Review the provider exclusions list
The Centers for Medicare and Medicaid Services (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 |
|---|---|
Office of Inspector General List of Excluded Individuals and Entities (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. |
Suspended and Ineligible Provider List (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. |
FEHBP | Providers suspended and debarred from participating in the Federal Employee Health Benefit Program which precludes the provider from participating in all other federal agencies’ procurement and no procurement programs and activities. |
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)
|
FEHBP | All lines of business | Federal Employee Program |
|
Additional information
Relevant sections of the 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 on the provider portal > Provider Library under Quick Links or go directly to provider library.
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
If you would like a copy of the latest Restricted Provider Database (RPD) data file, subcontractors and delegated entities should submit a request to Health Net by email.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.