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Forms and Brochures – California

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Claims


Medical Claim Form for Group and Individual & Family Plans

English 1.4MB   04/23/20

En Español (Spanish) 1.2MB   04/23/20

Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. PLEASE ATTACH FULLY ITEMIZED BILLS AND PROOF OF PAYMENT.

Proof of payment includes:

  • Copy of cancelled check (front and back) or online bank statement
  • Copy of credit card statement or bank statement

NOTE:

  • Proof of payment on a Dr.'s prescription form is not acceptable.
  • Invoices are not acceptable forms of proof of payment.


Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire

English 647kB   10/10/18


Non-Medicare – Behavioral Health (MHN) – Claim Form

English 2.9MB   03/28/19


Dental Claim Form

English 2.8MB   01/09/09


Medicare Supplement Plan Claim Form

English 26kB   11/26/07


Out-of-Network Vision Claim Form (non-Medicare)

English 512kB   06/27/17


Enrollment


Small Group Enrollment/Change Form

English 708kB   12/12/19

En Español (Spanish) 687kB   11/18/19

Chinese (Chinese) 952kB   11/18/19

Korean (Korean) 777kB   11/18/19

Vietnamese (Vietnamese) 706kB   11/18/19


Large Group Enrollment/Change Form

English 1.7MB   01/28/20

En Español (Spanish) 1.1MB   01/28/20

Chinese (Chinese) 1MB   01/28/20

Korean (Korean) 835kB   01/28/20

Vietnamese (Vietnamese) 759kB   01/28/20


Health Net Life Group Employee/Dependant Enrollment Form

English 983kB   12/10/19

English 612kB   12/10/19

English 932kB   09/19/11


HSA for Life - Enrollment Packet

English 124kB   01/29/19

For enrolling in a Health Savings Account (HSA)


Hardship Exemption Form

English 178kB   01/21/16


Other Helpful Forms


First Health Provider Nomination Form

English 185kB   01/14/20

You can save a lot by using a doctor who participates in the First Health Network. That's why we make it easy for you to nominate him or her to join.


Continuity of Care Assistance Request Form

English 2.6MB   01/24/20

En Español (Spanish) 932kB   01/24/20


Disabled Dependent Certification Form

English 504kB   05/09/19


Out-of-Pocket Maximum Notification

English 513kB   01/30/20


Pharmacy

Mail Order Pharmacy

CVS Caremark Mail Order Pharmacy

English 630kB   06/22/20

En Español (Spanish) 566kB   06/22/20


Medication Therapy Management

Personal Medication List

English 713kB   01/07/20


Prescription Claims

Prescription Drug Claim Form (Medicare Members)

English 144kB   02/01/19

En Español (Spanish) 338kB   02/01/19


Prescription Drug Claim Form (Commercial Members)

English 661kB   01/07/20

En Español (Spanish) 654kB   01/07/20


Prescription Transition Form

Prescription Transition Form (Commercial Members)

English 2.1MB   07/23/20

En Español (Spanish) 2.6MB   07/23/20


HIPAA Compliance


Authorization For Disclosure of PHI

English 568kB   05/29/19

En Español (Spanish) 558kB   05/29/19

Chinese (Chinese) 769kB   05/29/19

Korean (Korean) 671kB   05/29/19


Glossary of Health Coverage and Medical Terms


Glossary of Health Coverage and Medical Terms

English 117kB   07/22/16

En Español (Spanish) 138kB   07/22/16

Chinese (Chinese) 447kB   07/22/16

Navajo 230kB   07/22/16

Korean (Korean) 1.2MB   07/22/16

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.



Information last updated 07-23-2020

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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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Schedule of Benefits Disclaimer

This Schedule of Benefits is a brief list of benefits, with applicable copayments, coinsurance and deductibles information for your health plan. It does not list the exclusions and limitations or other important terms applicable to your plan.

For more information, please review carefully the disclosure form for your plan. It includes additional terms and information on certain exclusions and limitations.

The Evidence of Coverage (EOC) for your plan contains the complete terms and conditions of your Health Net coverage. It is important for you to thoroughly review the disclosure form and EOC for your plan, especially those sections that apply to those with special health care needs. You may view your Evidence of Coverage by: closing the current window and clicking on MY MEDICAL BENEFITS.

You may request copies of the forms referenced above for your health plan by: closing this window and clicking on Contact Us at the top of any web page.
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How do I add or delete family members (ex. newborns,adoptions)?

You may add or delete family members during your open enrollment period. In addition, we will generally accept enrollments for newly eligible members within 30 days after the following events (with proper documentation submitted to us):



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This enrollee's premiums are past due. Coverage will be suspended if premiums remain past due for more than 1 month. When coverage is suspended, outstanding authorizations for service are no longer valid. And there is no further coverage for any services rendered unless premiums are paid in full by the end of a 3 month grace period. Please contact us for more information.

This enrollee's premiums are more than 1 month past due. Coverage is currently suspended due to non-payment of premiums. Outstanding authorizations for service are no longer valid. There is no further coverage for any services rendered unless premiums are paid in full by the end of a 3 month grace period. Please contact us for more information.

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