Electronic Data Interchange (EDI)
What is EDI?
Electronic data interchange (EDI) is the exchange of business transactions in a standardized format from one computer to another. Health Net of California, Health Net Health Plan of Oregon, Inc and Health Net Life Insurance Company (Health Net) and providers use this technology to communicate claims, electronic remittance, claims payment, eligibility, and other information, providing a paperless and efficient process.
EDI gives you the tools you need to track electronic claims status, improve timely filing, and access daily accept/reject reports. This also means easier receivables and account reconciliation. By using Health Net-approved vendors and clearinghouses, HIPAA compliance is done for you, and you will have automatic access to highly secure and time-tested solutions.
Health Net has the following transactions available for providers through one of our approved clearinghouses: 837 electronic claim submission, 835 electronic remittance advice, and EFT payments. We are CORE Phase III certified with our real-time claims status and member eligibility transactions as well as compliant with the federal operating rules.
Submit claims through a clearinghouse
For successful EDI claim submission, you will need to use electronic reporting made available by your vendor and/or clearinghouse. Health Net returns claims acknowledgements to the clearinghouse with notifications of acceptance or rejection of individual claims. Providers can review these reports to check the status of their submission.
Health Net processes anesthesia, medical, coordination of benefits (COB), hospital, and surgical claims electronically. We accept electronic claims directly from Availity, Change Healthcare and Ability. Claims regarding other benefits, including certain mental health, complementary treatments, pharmacy, and outpatient radiology are administered for Health Net by outside vendors and claims are processed by each vendor accordingly.
Our partnership with MD On-line/Ability allows even the smallest practice to take advantage of EDI savings, for free. Using this web-based solution, you can submit direct to Health Net on-line.
Submitting claims directly to Health Net (through Ability)
In partnership with Ability Network, Health Net now gives providers the option of exclusively submitting Health Net claims for free through a private label website that links directly from www.healthnet.com. The two products offered on the site allow providers to submit claims using either their own practice management software or direct data entry. The latter allows smaller practices to take advantage of the benefits of submitting claims electronically without having to bear the expense of specialized software. Providers may also use Ability services as an all payer solution for which standard Ability fees may apply.
Submitting claims to Health Net through Change HealthCare and Availity
Health Net has contracted with Change Healthcare and Availity to provide claims clearinghouse services for Health Net claim submission. These partners will work with your clearinghouse or vendor to get the claims submitted to Health Net in a timely manner.
Benefits of electronic claim submission include:
- Reduction/elimination of costs associated with printing and mailing paper claims.
- Improvement of data integrity through using clearinghouse edits.
- Faster receipt of claims by Health Net, resulting in reduced processing time and quicker payment.
- Confirmation of receipt of claims by the clearinghouse.
- Availability of reports when electronic claims are accepted and rejected.
- Ability to track electronic claims, resulting in greater accountability.
For successful EDI claim submission, providers/facilities must utilize the electronic reporting made available by their vendor/clearinghouse. There may be several levels of electronic reporting:
- Confirmation/rejection reports from EDI vendor
- Confirmation/rejection reports from EDI clearinghouse
- Confirmation/rejection reports from Health Net
Providers may also check the status of paper and electronic claims via our claims status transaction available through Change Healthcare or online at HealthNet.com. Registration is required.
Providers are encouraged to contact their vendor/clearinghouse to see how these reports can be accessed/viewed. All electronic claims that have been rejected must be corrected and resubmitted. Rejected claims may be resubmitted electronically.
Electronic Remittance Advice and Electronic Funds Transfer from Health Net
Electronic Remittance Advice (ERA)
Health Net has further streamlined our business processes to improve claims procedures. Providers can now register to receive Electronic Remittance Advices (ERA). These features streamline claim processing, reduce administrative work and improve provider satisfaction by reducing claims-related problems.
ERA files give providers details regarding multiple claims. ERA improves providers' business office workflow by allowing the adjudicated claim information to automatically post to accounts receivable systems. Health Net will send an ERA to any provider who registers with Health Net and with a clearinghouse. ERA is available in all Health Net service areas.
Electronic Funds Transfer (EFT)
EFT automates the distribution of funds into providers' accounts using Automated Clearinghouse (ACH) processing. EFT is the electronic mechanism used to instruct Depository Financial Institutions (DFIs) to move money from one account to another. Many formats are available for the actual data in the electronic message, and different formats apply at each stage. EFT is safe, secure, efficient, and less expensive than paper check payments and collections. A separate registration form is required. Get help from Health Net's EDI specialists. Please contact the Health Net Provider Services Center regarding all claim adjudication issues regardless of submission method.
If you are a participating Health Net network provider and have a HealthNet.com account, please log in before enrolling in EFT or ERA. Failure to do so will delay processing and could result in a rejection.
For Health Net Employer group, MA HMO, HMO, PPO and EPO; POS, CommunityCare, Centene Corporation Employee Self-Insured PPO, Medi-Cal (including CalViva Health) and/or Cal MediConnect, please register on-line at healthnet.com.
ERA and EFT require separate registration. You can register for just ERA, just EFT or both.
Register Online or Download Enrollment Forms
- ERA – Electronic Remittance Advice Online Enrollment
- EFT – Electronic Funds Transfer Online Enrollment
Download Enrollment Forms
- ERA – Electronic Remittance Advice Authorization Agreement (PDF)
- EFT – Electronic Funds Transfer Authorization Agreement (PDF)
For members enrolled with Ambetter, Medicare Advantage (Allwell) and CA on and off Exchange
Providers must enroll with PaySpan to enroll in the ERA and EFT program to obtain access to ERA and EFT delivery services.
A unique registration code is required for registration with Payspan. A registration code can be requested by any of the following methods:
- Online registration with Payspan
- Via email – Provider Support Payspanhealth.com
- Contact Payspan Provider Services at 1-877-331-7154, Option 1
Registration codes requested online or via email will be emailed from Payspan along with detailed registration instructions.
Using EDI for Eligibility & Benefits Verification
HIPAA Standard 270/271 Eligibility Transactions
Requests for eligibility status for a single commercial, Medicare or state health programs member transaction may be submitted by registered participating providers on the Health Net provider website. Select the appropriate Verify Eligibility link under Eligibility & Benefits to the left to get started.
To request eligibility and obtain eligibility information for multiple members at one time, providers can use the 270/271 eligibility transaction through one of two electronic clearinghouses. A 270 request provides eligibility verification information directly to providers through a real-time link. Providers submit a request for a single HIPAA standard 270 or multiple 270s and obtain the 271 responses from Health Net online.
271 responses are also compliant with the Council for Affordable Quality Healthcare (CAQH®)/Committee on Operating Rules for Information Exchange (CORETM) Phase II requirements.
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) privacy requirements for submission of electronic health care transactions, Health Net is compliant in meeting and adopting the 270/271 eligibility transaction standards as outlined by HIPAA and with the Administration Simplication Operating rules for eligibility and health care claim status transactions. Check with your vendor/clearinghouse for sending/receiving eligibility requests using the 270/271 real time transaction or contact one of the Health Net clearinghouses listed below to set up the HIPAA standard 270 request:
Using EDI for Claim Status Verification
HIPAA Standard 276/277 Claim Transactions
Requests for claims status for a single commercial, Medicare or state health programs member transaction may be submitted by registered participating providers on the Health Net provider website. Select the appropriate Verify claims link under Eligibility & Benefits to the left to get started.
To request claims status information for multiple members at one time, providers can use the 276/277 claims transaction through one of three electronic clearinghouses. A 276 request provides claims status information directly to providers through a real-time link. Providers submit a request for a single HIPAA standard 276 or multiple 276s and obtain the 277 responses from Health Net online.
276 responses are also compliant with the Council for Affordable Quality Healthcare (CAQH®)/Committee on Operating Rules for Information Exchange (CORETM) Phase II requirements.
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) privacy requirements for submission of electronic health care transactions, Health Net is compliant in meeting and adopting the 276/277 claim transaction standards as outlined by HIPAA and with the Administration Simplification Operating rules for health care claim status transactions. Check with your vendor/clearinghouse for sending/receiving claim requests using the 276/277 real time transaction or contact one of the Health Net clearinghouses listed below to set up the HIPAA standard 276 request.
|Clearinghouse||Contact Information||Health Net payer ID CA & OR|
Payer IDs for claim submissions:
|Line of business||HEALTH NET PAYER ID CA & OR
Individual MA HMO, Special Needs Plan (SNP) (does not apply to employer group MA HMO)
Employer group MA HMO, HMO, PPO, EPO, Point of Service (POS), Medi-Cal (including CalViva Health), Cal MediConnect, Centene Corporation Employee Self-Insured PPO Plan
If your request is regarding claim denial, claim appeal status or web support issues, please contact the health plan directly. If your request is EDI related, please contact the EDI Solution Center, preferably by email, at the contact location listed below. Please provide your name, telephone number, claim submission ID, health plan name and a description of the issue with your request.