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Forms and Brochures – California

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To view or download a file, click the desired language link. The PDF file will open in a new window or tab of your browser. From there, you can also download or print the file. To send by email, select the check box next to the item(s) of your choice and click the "Email" button at the bottom of this page.



Claims


Medical Claim Form for Group, Individual & Family Plans

English 127kB   04/28/15

Español (Spanish) 113kB   04/28/15

Chinese (Chinese) 397kB   04/28/15

Did you know ? We've made it easier to request a reimbursement for a medical claim. You can now begin a pre-filled request form online, then just print, and submit. Go to our new online Medical Reimbursement Request.


IFP & Group Member Grievance Form

English 18kB   11/06/13

Chinese (Chinese) 116kB   11/06/13

Español (Spanish) 19kB   11/06/13

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.


Dental Claim Form

English 2.8MB   01/09/09


Foreign Claims Questionnaire for Group, Individual and Family Plans

English 71kB   04/28/15

Español (Spanish) 456kB   04/28/15

If you were traveling outside of the United States and had to seek urgent medical care, please complete this form and send as directed. This form is intended for use by Health Net's non-Medicare members.


Medicare Supplement Plan Claim Form

English 26kB   11/26/07


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

English 81kB   01/21/10


Enrollment


Individual & Family HMO/HSP Enrollment Application

English 3.2MB   12/04/14

Download only


Individual & Family PPO Enrollment Application

English 3.1MB   12/04/14

Download only


Individual & Family EPO Enrollment Application

English 3.2MB   12/04/14

Download only


Simple Pay Option Form (ABD) - Post-enrollment

English 467kB   12/05/14

Member use only if first payment has been made. Download only.


Glossary of Health Coverage and Medical Terms

English 92kB   09/11/12

Español (Spanish) 357kB   08/28/13

Chinese (Chinese) 231kB   08/28/13

Navajo 409kB   08/28/13

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.


Membership


First Health Provider Nomination Form

English 87kB   04/28/10

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 - HMO Members

English 74kB   12/19/13

Español (Spanish) 1.4MB   09/02/09


Continuity of Care Assistance Request Form - PPO Members

English 74kB   12/19/13


HN Life Group Employee/Dependant Change Form

English 578kB   11/11/08

Chinese (Chinese) 1.4MB   08/05/08

Español (Spanish) 397kB   08/05/08


IFP Accident Waiver Deductible Request Form

English 13kB   05/25/04

This form must be received by Health Net Life within 60 days of the accident date of service. Please refer to your Policy for details on the accident waiver.


Disabled Dependent Certification Form

English 479kB   05/18/13


Out-of-pocket Maximum Notification

English 92kB   01/30/14


Mid Market/Large Group Enrollment/Change Form

English 2.1MB   09/01/09

Español (Spanish) 2.3MB   09/01/09

Chinese (Chinese) 7.8MB   09/01/09


Small Business Group Employee Enrollment and Change Form

English 1MB   03/12/14

Español (Spanish) 973kB   04/18/14

Chinese (Chinese) 1.2MB   04/18/14

Must be completed & submitted at time of enrollment in order to enroll new employees & existing dependents. Also used for employees/dependents waiving coverage.


Pharmacy

Mail Order Pharmacy

Mail Order Pharmacy Form

English 1.1MB   03/10/15

Español (Spanish) 1.1MB   03/10/15


Getting Started with Mail Order Brochure

English 384kB   02/25/15

Español (Spanish) 658kB   11/24/08


Medication Therapy Management

Personal Medication List

English 24kB   02/19/14


Prescription Claims

Prescription Drug Claim Form (Medicare Members)

English 156kB   01/30/14


Prescription Drug Claim Form (Commercial Members)

English 186kB   06/26/13

Español (Spanish) 199kB   09/22/14


Prescription Transition Form

Prescription Transition Form (Commercial Members)

English 54kB   11/19/14

Español (Spanish) 43kB   11/19/14

Chinese (Chinese) 737kB   11/19/14

Korean 611kB   11/19/14


HIPAA Compliance


HIPAA Authorization Form

English 575kB   04/16/13

Español (Spanish) 586kB   04/16/13

Chinese (Chinese) 487kB   04/16/13



Information last updated 04-02-2014

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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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