24-130m Update to the Provider Suspended and Exclusion Lists
Date: 02/09/24
Providers are encouraged to review and verify provider eligibility on a regular basis to avoid termination
Effective January 1, 2024, providers may access the Office of Personnel Management under the Federal Employee Health Benefit Plan sanction and debarment list and the Restricted Provider Database list through the Plan provider website.
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 or at least monthly.
Review the provider exclusions lists
The following lists include providers excluded from activities such as rendering services to enrollees and/or employment or contracting to provide services to enrollees. For details on the provider exclusion list, how providers are affected and how to access the list, below.
- 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.
- Restricted Provider Database (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.
- Federal Employee Health Benefit Plan (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 non-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 | Distributed to providers:
Once on the Healthnet.com site, select the Working with Health Net tab > Regulatory > Medicare Information. |
CMS Preclusion List | All lines of business | Medicare | Distributed to providers by the Plan.
Once on the Healthnet.com site, select the Working with Health Net tab > Regulatory > Medicare Information. |
FEHBP | All lines of business | Federal Employee Program | Distributed to providers:
Once on the Healthnet.com site, select the Working with Health Net tab > Regulatory > Medicare Information. A 12-month claims look-back review must occur for all identified participating and non-participating providers. Federal Employee Health Benefit Plan members identified through the claims review must receive notification that the provider is no longer available to receive services from. |
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.
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 Community Health Plan of Imperial Valley at 833-236-4141.
If you would like a copy of the latest Restricted Provider Database 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 Imperial county.