24-1090m Use Updated Templates to Notify Members of Specialist Terminations
Date: 10/09/24
New templates apply to specific Dual Special Needs Plans and Medicare Advantage products
Participating physician groups (PPGs) must use updated letter templates to notify members of specialist terminations. PPGs must use the templates approved by the Centers for Medicare & Medicaid Services.
Download the templates
Download the templates in the Forms and References section of the Provider Library.
Use the respective template that corresponds to the H-contract number for the products indicated in the chart below. The H-contract number is shown in the template’s footer and in the name of the file available for download in the Provider Library.
Template | H-contract | Product |
Medicare Provider Termination Notification Template-MA H0562 | H0562 | Medicare Advantage |
Medicare Provider Termination Notification Template-DSNP H3561 | H3561 | Dual Special Needs Plans:
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Additional information
Relevant sections of Health Net’s provider operations manuals and the Behavioral Health Provider Operations Manual have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone 800-929-9224 or through the Health Net provider portal. Behavioral health providers can call 844-966-0298.
This information applies to Physicians, Participating Physician Groups (PPGs), and Behavioral Health Providers.