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Approved Vendors

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Approved Vendors


Claims Submission


Health Net has contracted with Capario, Emdeon/WebMD, and MD On-Line 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 the use of 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
Clearinghouse Telephone Number Web Site Health Net Payer ID
CA & OR AZ
Capario (MedAvant) AZ, CA & OR
1-888-894-7888		 www.capario.com 95567 38309
Emdeon/WebMD 1-877-469-3263 transact.emdeon.com HNNC HNNC
As a result of our partnership with MD On-Line, all payer claims can be submitted electronically via Health Net's Web site, Healthnet.com.
MD On-Line 1-888-499-5465 healthnet.com
mdon-line.com		 95567 38309
Reports

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 Emdeon 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.

For questions regarding electronic claim submission, please contact Health Net's dedicated EDI line:

California and Oregon: 1-800-977-3568
Arizona, Connecticut, New Jersey, New York: 1-866-334-4638


Electronic Payment and Remittance Options


Frequently Asked Questions


Health Net offers electronic remittance advice (ERA) and electronic fund transfer (EFT) to reduce:



What is ERA?

ERA provides details on multiple claims and helps improve business office workflow by allowing the adjudicated claim information to be automatically posted to accounts receivable systems. Health Net sends an ERA to any provider who registers with an approved clearinghouse. The ERA complies with HIPAA 835 requirements making it consistent with other payers and is acceptable nationwide.

What is EFT?

EFT automates the distribution of funds into accounts using automated clearinghouse processing to reconcile accounts receivable, which provides significant savings in check processing fees. Before EFT, providers were required to open the mail, pull the check, enter the data into their system, get the checks to the bank, wait for them to clear, reconcile books, and more. EFT is safe, secure, efficient, and less expensive than paper check payments and collections.

How do I get started?

Register with both Health Net and one of our approved clearinghouses. Download Health Net registration forms from below Forms and Brochures.

What are the details for enrolling in ERA?

Health Net sends ERA via Emdeon, Capario (MedAvant) and Healthcare Electronic Remittance Advice Exchange (HERAE). To enroll, please contact the following clearinghouses directly:

To enroll in ERA, complete the ERA Enrollment form and fax it, along with a voided check, to 1-800-677-4147, Attention: EDI Business.

What are the details for enrolling in EFT?

You must be registered for ERA in order to enroll in EFT. Download Health Net registration forms from below Forms and Brochures.

To enroll in EFT, complete and sign the EFT Enrollment form and fax it to 1-800-677-4147, Attention: EDI Business.

Who can I contact for help?

Health Net's specialists are on call for you. Please email EDI.Support@healthnet.com or call our dedicated ERA/EFT help line:

For AZ - 1-866-334-4638, option 3
For CA/OR - 1-800-977-3568


Download or print forms and brochures

ERA Enrollment Form


Print or download pdf

EFT Enrollment Form


Print or download pdf
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Important Notice

General Purpose
Health Net's National 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 government 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 suppply 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 elibible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicats 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, new or revised policies require prior notice or posting on the website 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, new or revised policies require prior notice or website posting 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 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.
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. Coverage decisions are the result of the terms and conditions of the Member's benefit contract. The Policies do not replace or amend the Member's contract. If there is a discrepancy between the Policies and the Member's contract, the Member's contract shall govern.

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 co-payment, 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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