The following are some pointers on claims submissions, the HIPAA glossary of EDI terms and frequently asked questions (FAQ).
Here are some tips from our EDI specialists for successful claims submission:
Providers in Connecticut, New Jersey, New York, Pennsylvania, and Arizona
Use the six (6) character alpha-numeric provider ID assigned by Health Net
Avoid the use of dots, dashes or special characters in the member ID, procedure code or diagnosis numbers
Send only one date of service per line (Hospitals may submit multiple dates)
Double check your unique six (6) character alpha-numeric provider ID and take note of the letters versus the numbers
Health Net encourages the electronic submission of all claims, however supporting documentation may be requested for the following types of claims through an Explanation of Benefits: Coordination of Benefits (COB) as well as for certain mental health charges, complementary treatments, pharmacy and regional out-patient radiology services
Providers in California, Oregon and Washington
Health Net Member IDs begin with the letter "R" followed by eight numeric digits. IDs do not contain the letter "O", always use the numeric zero (0).
Submit license information for the Rendering, Referring and Attending providers.
Health Net processes Medical, Hospital, Anesthesia, Surgical and ER claims electronically from both participating and non-participating providers.
Health Net encourages the electronic submission of all claims, however supporting documentation may be requested for the following types of claims through an Explanation of Benefits: COB, StopLoss, Trauma and Newborn NICU claims.
Submit claims with the patient's name and birth date exactly as it appears on their Health Net ID card.
Avoid timely filing issues through understanding and regular monitoring of EDI Reports. This process may help ensure all rejected claims are re-filed timely and electronically.
Vendor/clearinghouse Initial Acceptance report may be submitted as proof of timely filing.
Q. Can claims be paid faster if I submit them electronically?
Yes. Electronic claims are generally received in less time than those sent via the mail. Thus, processing time is often reduced.
Q. Are there costs associated with electronic claims submission through a clearinghouse?
A. There are many options for electronic claim submission. Depending on the needs of your organization, there may be costs associated. Clearinghouses should be contacted directly so needs and options can be discussed.
In partnership with MD On-Line, Health Net now gives providers the option of exclusively submitting Health Net claims for free through a private label Web site 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 MD On-Line's services as an all payer solution for which standard MD On-Line fees apply.
Q. What are the advantages of submitting my claims through MD On-Line?
A. There is many options for electronic claim submission with MD On-Line. Depending on the needs of your organization, there may be some costs associated. Also it is not necessary to test directly with Health Net.
Q. What are the advantages of submitting my claims through a clearinghouse?
A. Submitting through a clearinghouse has many advantages including:
It is not necessary to test with Health Net. Clearinghouses are HIPAA compliant.
Payer reports are submitted electronically through the clearinghouse vs. being sent via mail.
Clearinghouses will make available to providers the initial acceptance report confirming receipt of your claims by your clearinghouse and the payer. Payer Acceptance/Rejection reports can be used as proof of timely filing.
Initial Acceptance Report: This report shows your clearinghouse accepted the EDI Claim and forwarded it to Health Net for additional payer editing and processing. Please note that claims can pass clearinghouse edits, but still be rejected by Health Net.
Health Net Reject Report: This report shows that Health Net rejected the claim for "invalid subscriber ID number". Please note that a claim that is filed and "rejected" is not considered "received" by Health Net. These claims should be corrected and re-submitted electronically as soon as possible to avoid timely filing issues.
Clearinghouses will notify providers of updates on changes in Health Net's electronic claim submission policies.
Q. What if I am using a vendor/clearinghouse that is not on your list?
A. Many vendors/clearinghouses have agreements for transmitting EDI claims through other clearinghouses. Please contact your vendor/clearinghouse and verify connectivity to Health Net.
Q. Can non-participating providers submit claims electronically?
A. Yes. All claims can be submitted electronically from both Participating and Non-Participating providers. Click here to Get Started.
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