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Medicare Information

Medicare FWA, SNP Model of Care and
Provider Marketing Training

In accordance with Centers for Medicare and Medicaid Services (CMS) regulations, Medicare Advantage organizations (MAOs) are required to establish, implement and ensure that all first-tier, downstream and related entities (FDRs) have taken and reviewed the following trainings and educational materials:


Medicare Fraud, Waste, and Abuse Training

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage organizations (MAOs) to monitor and track its participating providers to ensure completion of the Fraud, Waste and Abuse (FWA) training requirements. For Cal MediConnect Plan (Medicare–Medi-Cal Plan) providers, these requirements are Medicare-specific, and not applicable to Medi-Cal.


FWA Training Requirements

Most of Health Net’s participating providers, or first-tier, downstream and related entities (FDRs), are deemed to have met the FWA training and education requirements due to their enrollment in Medicare Parts A or B, or have accreditation as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DME-POS). Therefore, this communication is directed to participating physician groups (PPGs), independent practice associations (IPAs) and medical groups and their employees.

Health Net PPG, IPA or medical groups delegated to perform administrative functions, such as claims processing, credentialing or utilization management, on behalf of Health Net are required to ensure their employees involved in these delegated functions receive FWA training within 90 days of initial hiring and annually thereafter by December 31, unless the PPG, IPA or medical group can demonstrate that they meet the requirements of the above deemed category.

CMS launched a standardized Medicare Parts C and D FWA training and education module through the CMS Medicare Learning Network (MLN) website under the Web-Based Training Courses link at:

Delegated PPGs, IPAs and medical groups should use this training module to satisfy the CMS training requirement for their administrative staff.

Training Attestation Record Maintenance Requirements

By March 31 of each year, delegated PPGs, IPAs and medical groups are required to attest that all identified staff completed the FWA training in the prior year. A parent PPG may submit one attestation on behalf of itself and its satellites. The attestation form may be faxed or emailed to Health Net’s Provider Network Management Department using the contact information provided on the form. There is an option on the attestation to indicate whether a PPG, IPA or medical group meets the requirements of the above deemed category. If this option is selected, supporting documentation must be faxed or emailed along with the attestation.

Delegated PPGs, IPAs and medical groups are accountable for maintaining FWA training records for a period of 10 years of attendance, topics, certificates of completion (if applicable), and test scores of any tests administered to their employees related to FWA training. This is subject to audit upon request from Health Net or CMS. Health Net continues to randomly conduct audits to ensure compliance with this requirement.


CMS FWA REGULATIONS AND REQUIREMENTS

These requirements are being implemented based on the following:

  • Title 42 Code of Federal Regulations (CFR) 422.503(b)(4)(vi)(C), 423.504(b)(4)(vi)(C)
  • CMS Medicare Managed Care Manual, Chapter 21 – Compliance Program Guidelines, and Prescription Drug Benefit Manual Chapter 9 – Compliance Program Guidelines, Section 50.3.2: Fraud, Waste, and Abuse Training

Additional Information (Health Net Providers and FDRs must ensure distribution of these documents to their employees and downstream entities within 90 days of hire, when updated, and annually thereafter):

Special Needs Plans Model of Care Initial & Annual Training

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage organizations (MAOs) to provide annual Special Needs Plans (SNP) Model of Care Annual training for all SNP participating providers (§422.102(f)(2)(ii)). In accordance with the regulations, Health Net has developed the SNP Model of Care Annual training. This requirement is applicable to SNP providers only.

CMS requires that SNP providers and appropriate staff (those involved in any aspect of the provision of SNP services) complete the SNP model of care annual training each year by December 31. The training can be provided in any of a variety of modalities, such as printed, face-to-face, Web-based, or audio and visual formats. SNP providers do not have to submit confirmation of training upon completion; however, providers are subject to audit by CMS and Health Net to demonstrate that the training was provided to appropriate staff. Therefore, providers must maintain training records, which may consist of a mailing list, fax list, sign-in sheet, or other formats. If you choose to use the model of care annual training that Health Net created, select SNP Model of Care Annual Training (pdf) to open the file and begin the training.

Medicare Compliance Provider Marketing Training

The Centers for Medicare and Medicaid Services (CMS) Medicare Managed Care Manual provides specific guidance regarding marketing communications to Medicare-eligible members by health plans and their participating providers, hospitals, and ancillary providers. Health Net participating providers are required to comply with applicable Medicare laws and regulations, and Health Net policies and procedures when creating or distributing marketing materials.

Health Net has developed the online Medicare Compliance Provider Marketing Training (pdf) in an effort to provide a high-level overview of the CMS marketing requirements, including appropriate supporting documents, responsibilities and where to find forms and guidance.

For questions regarding Medicare marketing materials submission, or to submit Medicare marketing materials for approval, contact the Health Net Medicare Marketing Department by email at:

For updated and additional information regarding CMS Medicare marketing guidelines, refer to the CMS website at:

Offshore Subcontracting Attestation

Offshore Subcontracting Attestation

All Health Net Medicare Advantage (MA) participating providers (also referred to as first-tier or downstream entities) who use offshore subcontractors to process, handle or access Health Net MA member protected health information (PHI) in oral, written or electronic form, must submit specific subcontracting information to Health Net. Health Net requires that participating providers do not allow any member data to be stored offshore. Subcontracted Offshore entities may only access member data through entities located in the United States (on-shore entities). Participating providers with offshore subcontracts must submit the following items:

  1. A completed and signed copy of the attestation form, available on the Health Net website. This attests that the participating provider has taken appropriate steps to address the risks associated with the use of subcontractors operating outside the United States. The attestation form includes the Health Net contact information for providers to return the completed form and materials.
  2. A copy of the agreement between the provider and offshore subcontractor (with proprietary information removed).
  3. A policy and procedure for ensuring and maintaining the security of Health Net MA members’ PHI.
  4. A policy and procedure that documents the process used for immediate termination of the offshore subcontractor upon discovery of a significant security breach.
  5. A policy and procedure that documents the process used for conducting annual audits, regular monitoring and tracking results, and resolving any identified deficiencies.

Providers must submit this information for each offshore subcontractor they have engaged to perform Medicare-related work, regardless of whether the information was already completed for a different plan. This information must be submitted to Health Net within 20 calendar days from the date the contract is signed with the offshore subcontractor or immediately upon knowledge of this requirement if the contract has been signed and is in place. Health Net is required to notify the Centers for Medicare and Medicaid Services (CMS) of its and its participating providers’ offshore subcontractor relationships.

If you have any questions regarding provider offshore subcontracting or to obtain a hard-copy of the attestation form, contact the Health Net Provider Services Center.

Information last updated 09-16-2014

Issue Identification, Tracking, Escalation, and Resolution Training

Issue Identification, Tracking, Escalation,
and Resolution Training

The Centers for Medicare and Medicaid Services (CMS) requires that Health Net operate in compliance with CMS regulations and report any issues that may be out of compliance. Therefore, Health Net requires that all Medicare Advantage (MA) first-tier, downstream and related entities (FDRs) report any issues that may be considered out of compliance to their Health Net business contact immediately upon learning of the incident. In addition, FDRs may report potential issues that may be considered out of compliance to Health Net as follows:


  • Health Net Medicare Compliance Officer
    Gay Ann Williams
    21650 Oxnard Street, Mail Stop: CA-102-22-07
    Woodland Hills, CA91367
  • Health Net's Fraud Hotline: 1-800-977-3565
  • Health Net's Integrity Line: 1-888-866-1366

All Health Net first-tier providers (those who hold a direct contract with Health Net) and downstream providers (entities with which a first-tier entity contracts to provide services to MA members) and first-tier and downstream employees must complete this training. First-tier entities are responsible for their downstream entities' completion of the training. Training must be completed annually by December 31 and must also be a part of orientation for new employees. This is subject to audit upon request from Health Net. This process is not related to and is separate from any provider appeals and grievance processes.

First-tier entities may download and distribute this training to their downstream providers.


Documentation Retention

Once a first-tier entity has completed the training, no further action is required. There are no acknowledgment or attestation forms to be returned to Health Net. First-tier entities must have documentation that the training was distributed to all of its employees and downstream entities and employees, as applicable, readily available for audit upon request from Health Net in the form of a mailing list, fax list or other equivalent format. Downstream entities do not need to submit acknowledgment or attestation forms to first-tier providers. Policies and procedures should also reflect inclusion of the training in new employee orientation processes.

To access hard-copy training, contact the Health Net Provider Services Center.


Code of Business Conduct & Ethics

Code of Business Conduct & Ethics

The Code of Business Conduct and Ethics is the cornerstone of Health Net's enterprise-wide compliance and ethics program and includes values and principles regarding acceptable business conduct. Honesty, integrity, transparency, and accountability are key concepts that Health Net embraces.

It is important that providers and first-tier, downstream and related entities (FDRs) read the Code of Business Conduct and Ethics in its entirety.

Health Net expects all Health Net providers and FDRs to read and understand Health Net standards of conduct and report any suspected violations of those standards. Health Net Providers and FDRs must ensure distribution of the standards of conduct to their employees and downstream entities within 90 days of hire, when updated, and annually thereafter.

Updates to Covered Benefits

Updates to Covered Benefits

Occasionally, the Centers for Medicare and Medicaid Services (CMS) will make mid-year changes to Original Medicare. These are known as National Coverage Determinations (NCDs).


Newly Required Preventive Services

The following preventive services are covered without cost-share, retroactive to October 14, 2011, according to the CMS' National Coverage Determination (NCD):

  • Screening and behavioral counseling interventions in primary care to reduce alcohol misuse
  • Screening for depression in adults in a primary care setting

The following preventive services are covered without cost-share, retroactive to November 8, 2011, according to the CMS' NCD:

  • Screening for sexually transmitted infections (STIs)
  • High-intensity behavioral counseling to prevent STIs

The following preventive services are covered without cost-share, retroactive to November 29, 2011, according to the CMS' NCD:

  • Screening for obesity and counseling for eligible beneficiaries by primary care providers

Additional Information

If you have questions regarding this information, refer to CMS' Web sites at CMS Coverage Email Updates and News and Announcements and select the applicable CMS press release. For all other questions, contact the applicable Health Net Provider Services Center.

Medicare Advantage Provider Exclusions Monitoring

Medicare Advantage Provider Exclusions Monitoring

The Centers for Medicare and Medicaid Services (CMS) require contractors and their First Tier Downstream and Related entities (FDRs) to monitor federal exclusions lists. The parties/entities on these lists are excluded from various activities, including rendering services to Medicare enrollees (unless in the case of an emergency, 42 CFR § 1001.1901) and from being employed or contracted to render services to Medicare enrollees. Health Net requires that its participating physician groups (PPGs), hospitals, ancillary providers, and physicians continuously monitor federal exclusion lists. The information below provides the names of each federal exclusion list, governing regulations and CMS guidance, including links to publically available exclusion lists.

HEALTH NET AND FDR HIRING AND CONTRACING RESPONSIBILITIES
Health Net and their First Tier Downstream and Related entities (FDRs) are required to monitor federal exclusion lists to ensure that Health Net and their First Tier Downstream and Related entities (FDRs) are not hiring, contracting or paying excluded parties or entities for services rendered to enrollees in Health Net’s MA and MA-PD plans. MAOs and their FDRs must check the List of Excluded Individuals and Entities (LEIE) and Exclusions Extract Data Package (EEDP) federal exclusion lists prior to hiring or contracting with any new employee, temporary employee, volunteer, consultant, governing body member, or FDR for Part C- and Part D related activities. MAOs and their FDRs must continuously monitor these lists at least monthly to ensure parties or entities that were previously screened have not become excluded later.

List of Excluded Individuals and Entities (LEIE)
The Office of the Inspector General -- Health and Human Services, (OIG-HHS) imposes exclusions under the authority of sections 1128 and 1156 of the Social Security Act.

Exclusions Extract Data Package (EEDP)
The General Services Administration (GSA’s) EEDP is a government-wide compilation of various federal agency exclusions, and replaces the Excluded Parties List System (EPLS). Exclusions contained in the EEDP are governed by each agency’s regulatory or legal authority. The EEDP also includes parties and entities from other federal exclusion databases. All parties or entities listed on the EEDP are subject to exclusion from Medicare participation.

  • The current EEDP is available on the SAM website at: www.sam.gov, with additional information located under Help > User Guides > Quick User Guides > Helpful Hints for Public Users.

HEALTH NET AND FDR PAYMENT RESPONSIBILITIES
Health Net and their First Tier Downstream and Related entities (FDRs): PPGs, hospitals, and ancillary providers cannot pay participating and non-participating parties or entities included on these lists for any services using federal funds, except as documented in the CMS Internet Only Manual, publication 100-16, Chapter 6 -- Relationships with Providers, which states, ‘‘The OIG has a limited exception that permits payment for emergency services provided by excluded providers under certain circumstances. See 42 CFR § 1001.1901.’’ FDRs contracting with Health Net and their First Tier Downstream and Related entities (FDRs) must have a documented process in place to ensure compliance with these guidelines, and notify enrollees who obtain services from excluded parties and make claims payments as allowed under these exceptions. This documentation is subject to audit upon request from Health Net or CMS.

GOVERNING REGULATION AND CMS GUIDANCE
The names of parties that have been excluded from Medicare participation are published in the Office of the Inspector General U.S. Department of Health and Human Services (OIGHHS) List of Excluded Individuals and Entities (LEIE), and on the General Services Administration’s (GSA) Exclusions Extract Data Package (EEDP) (or Excluded Parties List System (EPLS), which was replaced by the EEDP), as referenced through the System for Award Management (SAM) website at ww.sam.gov. Medicare Advantage organizations (MAOs) and their FDRs must abide by the regulations documented in the Social Security Act 1862(e)(1)(B), 42 CFR §422.503(b)(4)(vi)(F), 422.752(a)(8), 423.504(b)(4)(vi)(F), 423.752(a)(6), and 1001.1901. These federal exclusion requirements are further interpreted and communicated as guidance by CMS in Medicare Manual, Volume 100-16, Chapters 9 and 21 §50.6.8. Additional regulations that require sponsors to include CMS requirements in their contracts, as well as monitor their FDRs, are available in 42 CFR §422.504(i)(4)(B)(v) and 423.505(i)(3)(v).

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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Upload No Review - Terms of Use

I have elected to upload a zipped folder of care coordination documents in a pdf format using the specified file naming convention as set forth below. I understand the importance of ensuring that the file names are accurate and that they accurately identify the member(s) that the care coordination document(s) is/are associated with. I elected to upload the attached documentation and confirm submission without utilizing the review option because the files were generated and named systematically, not manually, and/or the files have been carefully audited and confirmed to be accurately named. By confirming my upload, I am representing that the file(s) is/are named accurately.


Document Type - File naming convention
PPG Care Plans - careplan_hnsubidpersonid_yyyymmdd.pdf
CBAS Care Plan - cbascp_hnsubidpersonid_yyyymmdd.pdf
CBAS Assessment - cbasa_hnsubidpersonid_yyyymmdd.pdf
MSSP Assessment - msspa_hnsubidpersonid_yyyymmdd.pdf
MSSP Care Plan - msspcp_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Assessment - mctna_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Care Plan - mctncp_hnsubidpersonid_yyyymmdd.pdf
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I have elected to upload a zipped folder of care coordination documents in a pdf format using the specified file naming convention as set forth below. I understand the importance of ensuring that the file names are accurate and that they accurately identify the member(s) that the care coordination document(s) is/are associated with. I have elect to upload of the attached documents and confirm submission using the review option. I certify that the files will be carefully audited and confirmed to be accurately named before confirming my upload. By confirming my upload, I am representing that the file(s) is/are named accurately.


Document Type - File naming convention
PPG Care Plans - careplan_hnsubidpersonid_yyyymmdd.pdf
CBAS Care Plan - cbascp_hnsubidpersonid_yyyymmdd.pdf
CBAS Assessment - cbasa_hnsubidpersonid_yyyymmdd.pdf
MSSP Assessment - msspa_hnsubidpersonid_yyyymmdd.pdf
MSSP Care Plan - msspcp_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Assessment - mctna_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Care Plan - mctncp_hnsubidpersonid_yyyymmdd.pdf
SNF MDS Form - snfmds_hnsubidpersonid_yyyymmdd.pdf
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File name example: careplan_R9999999900_20140505.pdf

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I am requesting to download care coordination documents on behalf of the Medical Group that I/we represent and the affiliated groups and entities. Furthermore, I understand that the files that I am requesting to download contain Protected Health Information ("PHI"), and that must be protected and only made available to affiliated Covered Entities for health care operational purposes consistent with 45 C.F.R. 164.501 and 506(c) and health care providers as defined by the Health Insurance Portability and Accountability Act ("HIPAA") that I/we have a treatment relationship with the patient(s).