The subscriber number can be found on your Health Net Insurance card. Please enter the complete ID, including all letters and numbers. All letters must be typed as capital letters.
The following information applies to all plans offered by Health Net of the Northeast, Inc.
Health Net will process claims received within 120 days after the later of the date of service and the date of the physician's receipt of an Explanation of Benefits (EOB) from the primary payer, when Health Net is the secondary payer. Health Net will waive the above requirement for a reasonable period in the event that the physician provides notice to Health Net, along with appropriate evidence, of extraordinary circumstances that resulted in the delayed submission. Health Net will determine "extraordinary circumstances" and the reasonableness of the submission date. This in no way limits Health Net's ability to provide incentives for prompt submission of claims. Health Net recommends that self-funded plans adopt the same time period as noted above.
Health Net accepts both properly completed paper claims submitted on CMS-1500 (for professional services) and UB 92 (for facility services) claim forms or the equivalent, and also electronic claims populated with similar information in HIPAA-compliant format or fields. Health Net does not require non-participating physicians to utilize electronic transactions. Health does require submission of additional information in connection with review of specific claims; provided that this does not alter or limit any restrictions concerning Health Net's ability to make requests for Clinical Information in connection with adjudication of claims. For additional information regarding claims submission and requests for additional information refer to Submit Claims. Participating providers can obtain additional information regarding the appropriate format for claims submissions and requests for additional information in the Operations Manual available in the Provider Library, under policies and procedures.
The following describe the elements of a complete claim:
When submitting claims all providers must include, at a minimum, all of the following required information:
Additional information required for selected providers includes:
Health Net applies standard American Medical Association (AMA), Current Procedural Terminology (CPT), Centers for Medicare and Medicaid Services (CMS), National Correct Coding Initiative (NCCI) guidelines, and other commercially reasonable coding practices adopted by Health Net to non-participating provider claims.
We expect non-participating providers to comply with standard coding practices.
If you have questions, contact the Provider Services Department at (800) 438-7886.
Health Net will make every attempt to identify claims overpayments and provide 30 days notice for overpayment refunds to be made. If a provider receives an Overpayment Refund Request letter from Health Net, the provider is to follow the instructions outlined in the letter for returning the overpayment or disputing the request. However, in the event that a provider independently identifies an overpayment from Health Net, the following steps should be taken:
The overpayment refund and applicable details should be sent to the following address for:
Health Net Overpayment Recovery Department
1 Far Mill Crossing
P.O. Box 904
Shelton, CT 06484
If a provider is contacted by a third party overpayment recovery vendor acting on behalf of Health Net, such as AIM, Rawlings, GB Collects or ORS, the provider should follow the overpayment refund instructions provided by the vendor.
If a provider believes that they have received a Health Net check in error and the provider has not cashed that check, the Health Net check should be returned to the address noted above with the applicable Remit Advice and a cover letter indicating why the check is being returned.
Health Net of the Northeast, Inc. routinely requires clinical information at the time of claim submission for the following scenarios:
By Diagnosis Code
|700||Corns and callosities|
|701||Other hypertrophic and atrophic conditions of the skin|
|701.9||Unspecified hypertrophic and atrophic conditions of skin|
|709||Other disorders of skin|
|709.2||Scar conditions and fibrosis of skin|
|V50||Elective surgery for purposes other than remedying health states|
|V50.0||Elective surgery; hair transplant|
|V50.1||Elective surgery; other plastic surgery for unacceptable cosmetic appearance|
|V50.8||Elective surgery; other|
|V509||Elective surgery; unspecified|
By Report Procedures
|11920||CORRECT SKIN COLOR DEFECTS|
|11921||CORRECT SKIN COLOR DEFECTS|
|11960||INSERT TISSUE EXPANDER(S)|
|11971||REMOVE TISSUE EXPANDER(S)|
|21089||PREPARE FACE/ORAL PROSTHESIS|
|21208||AUGMENTATION OF FACIAL BONES|
|21209||REDUCTION OF FACIAL BONES|
|21244||RECONSTRUCTION OF LOWER JAW|
|21245||RECONSTRUCTION OF JAW|
|21246||RECONSTRUCTION OF JAW|
|21270||AUGMENTATION, CHEEK BONE|
|37501||VASCULAR ENDOSCOPY PROCEDURE|
|99082||UNUSUAL PHYSICIAN TRAVEL|
Health Net of the Northeast, Inc. reserves the right to request clinical records before or after claim payment to identify possible fraudulent, wasteful or abusive activities, as well as any other activity not consistent or compliant with the applicable Health Net, regulatory, state and federal guidelines, provided there is evidence or information indicating such an investigation is deemed warranted.
Health Net's focused claim review program is comprised of two components, which are:
Claim reviews are conducted by OrthoNet by same-specialty physicians or surgeons.
Operative or procedure notes, as applicable, for selected services must be submitted to OrthoNet. If required operative or procedure notes are not submitted to OrthoNet, OrthoNet contacts the provider’s office to obtain them. The billed coding on these claims is reviewed against the related operative or procedure notes for the services outlined above. If requested notes are not received by OrthoNet within 30 days of the request, the related claim is denied by Health Net.
The purpose of the focused claim review program is to confirm that selected claims were properly coded and payable and supported by the operative or procedure notes received. If all services billed on a claim are supported by the operative or procedure notes, as applicable, then Health Net adjudicates the claim subject to all standard processing edits in place. Billed services not supported by the related operative or procedure notes are not allowed for payment.
This program is separate from any other audit or retrospective claim review that Health Net may conduct.
Claims submitted for the services with certain current procedural terminology (CPT) codes for which Health Net's allowed amount for the claim exceeds the dollar amount indicated are included in the focused claim review program.
Operative or procedure notes for selected services must be submitted to OrthoNet at the following address or fax number:
P.O. Box 5054
White Plains, NY 10605
Fax: (866) 999-5685
All claims for services must continue to be submitted to Health Net.