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Health Net Provider Alerts

3/24/20

COVID-19 (Coronavirus)

Questions and Answers for Health Net of California Network Providers

20-334c

Updated 4/6/20 – The following sections were added and/or updated with additional guidance and information:

  • Health Net's Business Continuity Plan (updated)
  • Telehealth (updated)
  • Babylon Health Telehealth Webinars (added 4/7/20)
  • COVID-19 Testing and Screening Billing Information (updated)
  • COVID-19 Screening and Testing (updated)
  • COVID-19 Related Treatments (added)
  • Reporting COVID-19 Impacts to Offices and Facilities (updated)
  • Additional Information, Requirements and Guidance (updated)

Request For Solutions: $5.9M In Grants For Telehealth Capacity Solutions (Deadline: 12pm PT, April 7, 2020)

Health Net is committed to protecting the delivery system for California's most vulnerable populations, especially those who serve the Medi-Cal community. In response to the COVID-19 pandemic, Health Net will provide one-time funding to California safety net clinics, Federally Qualified Health Centers, and independent provider practices to help build telehealth capacity and capability.

Health Net expects to award approximately 47 grants, with a maximum grant amount of $125,000 per award.

Telehealth Capacity

Telehealth funds are offered to assist with virtual visits between patients and providers. Telehealth is a service requirement in response to COVID-19, and we recognize Medi-Cal providers may need assistance to meet this requirement. Funds provided will be directed toward those providers who have limited and/or no telehealth infrastructure, and may also support the build out and/or significant expansion of current telehealth capacity.

Telehealth and Telephonic Infrastructure

  • Hardware, such as laptops, land lines and cell phones
  • Software
  • Licensing and vendor fees for telehealth programs and/or apps

Internet Services

  • Internet connectivity and/or browser set up
  • Monthly service or coverage fees

General Support

  • Training
  • Technical Assistance
  • Unanticipated operational, staffing and/or transitional costs associated with establishing and/or expanding telehealth visits

Telepsychiatry Infrastructure and Services

To increase prevention and intervention efforts for patients with mental health and/or substance use conditions

  • Telepsychiatry capability and capacity to sustain and/or expand access
  • Support training and/or team-based mental health modalities

Eligibility

  • To be eligible for COVID-19: Emergency Response Support, the applicant must be organized as one of the following:
    • Federally Qualified Health Center, Rural Health Center, Indian Health Center, 330 Look Alike Health Center, or community clinic
    • Independent Provider Practice with at least a 30% Medi-Cal patient mix and/or located in a Health Professional Shortage Area
  • Geographic Area: Safety Net Clinics and FQHCs operating in non-County Organized Health System (COHS) are eligible to apply
  • Must be able to document financial distress on current and/or future healthcare delivery operations
  • It is required that an applicant's telehealth solution or vendor have a billing process in place for telehealth, and have the capacity to collect and submit encounter data or claims data. Notwithstanding the Notification of Enforcement Discretion issued by the HHS Office of Civil Rights during the COVID-19 emergency response and telehealth services, it is strongly recommended the telehealth solution or vendor must meet HIPAA and related state privacy rules.

Request Specifications

Application

Please complete the online application found here: http://healthnet.smartsimple.com

Proposal Cover Letter

Please attach a letter on the organization's letterhead that includes, at a minimum:

  • The legal name of the organization
  • The organization's street address as listed in the application
  • Signature and date signed by the chief executive of the organization
  • Brief description of proposed program, including name of telehealth vendor/platform and requested funding amount

IRS Form W-9

Please provide a signed copy. The form for your fiscal agent will suffice if applicable.

Financial Report

Please provide a copy of your organization's most recent financial report, (such as YTD Budget Statement), that demonstrates financial distress for current and/or future healthcare delivery operations due to COVID-19. Please limit the report to five pages or less.

Accounts Payable ACH Form (for electronic deposit)

Payments will be electronically deposited into your organization's designated bank account through ACH. An ACH payment remittance advice will be delivered via the email address specified on the form. The form is to be completed by the requesting organization and must contain the signature of a company authorized individual. A link to download the form is provided in the application.

Key Dates

  • Proposal Release March 31, 2020
  • Proposal Due April 7, 2020, noon PST
Health Net's Business Continuity Plan

Updated 4/6/20 What is Health Net doing to mitigate risk to its operations?

As the COVID-19 situation escalates, we have taken the necessary steps to ensure the health of our employees so they can continue to perform their important work, and protect our business operations through actions such as implementing work from home policies where possible, providing enabling technology and limiting travel.

These and other measures further reinforce existing contingency plans Health Net has in place to preserve operations, provide our employees with the resources they need to stay safe, and support the health and well-being of our members during this critical time.

While this pandemic is unprecedented within Health Net's history, we are prepared for this challenge through our long-standing business continuity plans that safeguard the integrity of our operations.

As we have experienced in recent years as a result of seasonal wildfires and other natural disasters, Health Net regularly reviews and updates its emergency business continuity protocols. As part of these efforts, we continue to measure and refine our call center, utilization management and claims processing operations. We are doing everything we can during the nationally declared emergency for COVID-19 to support ongoing operations. In particular:

  • Health Net's Provider Network Management (PNM) and Provider Relations personnel remain available to providers, with no current impact in their ability to assist with provider issues.
    • However, on-site meetings are being replaced with telephonic and other forms of support.
  • Our key operational units will continue to provide updates to PNM leadership if and when challenges arise.
  • We have created the following website link, "Health Net Alerts: COVID-19" on provider.healthnet.com to provide regular updates.
Telehealth

Updated 4/6/20 Will Health Net allow access to telehealth services to increase access to care? And what is the reimbursement rate?

To limit members' risk of COVID-19 infection, Health Net encourages use of telehealth to deliver care when medically appropriate and capable through telehealth modalities for all services.

Commercial and Medi-Cal members - During the course of this declaration of emergency Health Net's coverage for telehealth services will be temporarily expanded in accordance with regulatory requirements, and will be reimbursed whether the telehealth service is delivered via audio/video technology or via audio-only technology (when deemed medically appropriate for the patient's medical condition).

Medicare and MMP/Cal MediConnect members - During the course of this declaration of emergency Health Net's coverage for telehealth services will follow guidance released by CMS, which includes telecommunications involving audio and video technology and audio only technology.

Applicable to all lines of business:

  • Health Net will reimburse fee-for-service providers the same contracted rate, whether service is provided in person or through telehealth technology.
  • Services that cannot be appropriately delivered remotely are not eligible for telehealth coverage and reimbursement.
  • Capitated physician groups or IPAs are required to support, cover and enable telehealth services and to abide by regulatory requirements for coverage and payment of telehealth services as outlined above.

In addition to telehealth services offered through our network of providers, Health Net is diligently working to offer expanded access to telehealth services through third parties. We will provide updated information on vendor arrangements once available.

Added 4/6/20 How do I bill for telehealth services during this declaration of emergency period?

For commercial and Medi-Cal

  • Use appropriate American Medical Association (AMA) CPT and HCPCS codes most descriptive for the service delivered
  • Use Place of Service code 02 (Telehealth) – excluding FQHC/RHCs
  • Use appropriate modifiers, when applicable – excluding FQHC/RHCs
    • Modifier 95 (Synchronous, interactive audio and telecommunications systems), OR
    • Modifier GQ (Asynchronous store and forward telecommunications systems)

The same amount of reimbursement will be provided for a service rendered via telephone as they would if the service is rendered via video provided the modality by which the service is rendered (telephone versus video) is medically appropriate for the member.

Updated Medi-Cal telehealth billing guidance, as well as information regarding FQHC telehealth coverage and billing guidance details, can be found at:

For Medicare and Cal MediConnect

  • Providers should bill and will be reimbursed for Medicare and Cal MediConnect telehealth services as required by CMS
  • Use Place of Service code 02 (Telehealth) and appropriate modifiers, when applicable

Updated CMS guidance for telehealth coverage can be found at: www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient

Examples of benefits or services not appropriate for telehealth delivery

Below are some examples (not exhaustive) of benefits or services that would not be appropriate for delivery via a telehealth modality:

  • Benefits or services that are performed in an operating room or while the patient is under anesthesia
  • Benefits or services that require direct visualization or instrumentation of bodily structures
  • Benefits or services that involve sampling of tissue or insertion/removal of medical device
  • Benefits or services that otherwise require the in-person presence of the patient for any reason

Added 4/6/20 Are there member cost shares for telehealth services delivered March 17 through June 30, 2020?

For telehealth services delivered March 17 through June 30, 2020, covered telehealth services will be offered at zero member cost share. This applies to:

  • All diagnosis codes, not just COVID-19 related diagnosis codes
  • Telehealth claims paid by Health Net and telehealth services covered and provided by capitated physician groups and IPAs.

Capitated Physician Groups/IPAs:

Capitated physician groups or IPAs are required to support, cover and enable telehealth services and to abide by regulatory requirements for coverage and payment of telehealth services as outlined above, including the waiver of member cost share. Waived cost shares for capitated physician groups' or IPAs' paid telehealth services will be reimbursed by the health plan. Details regarding the process for capitated telehealth services to receive reimbursement for waived member cost shares will be released at a later date.

Babylon Health Telehealth Webinars

Added 4/7/20 Join Health Net for an educational webinar on Babylon Health and their telehealth services.

Who should attend?

This opportunity applies to the following specialties, as providers contracted with Babylon Health will need to be able to serve patients from two years old and above with no restrictions:

  • Family medicine.
  • Emergency medicine.
  • Combined medicine-pediatrics.

Health Net is contracting with Babylon Health, a leading global provider of digital and virtual health care solutions, to help make telehealth available to our members. Babylon Health will provide access to telehealth services for all members statewide. Contracting directly with Babylon Health allows you to access a new revenue stream while also increasing access for Health Net members. If you are interested in contracting with Babylon Health, now is the time to become a Babylon Health provider.

What topics will be covered?

  • Review Babylon Health (California Telemedicine Associates, P.C.) and Health Net's relationship.
  • Overview of Babylon Health, a leading global provider of digital and virtual healthcare solutions.
  • Overview of Babylon's capabilities to help members and providers.
    1. Member journey flow
    2. Babylon Health app sample views
  • Outline provider opportunities to work with Babylon Health.
  • Review Babylon Health's support for providers.

What are the benefits to providers?

  • Competitive hourly rates to allow providers access to a much needed revenue stream.
  • Flexible work schedule with the ability to work from home.
  • Full clinical support to help with the administrative aspects of your consultations.
  • Full training program and a supportive environment to help improve your video consultation skills, including ongoing appraisals and peer reviews.
  • Access to a global network of like-minded providers who are passionate about delivering affordable and accessible health care to everyone on the planet!

What are the date and times?

Choose the date and time that works best for you; space is limited.

  1. Tuesday, April 14, 2020, 12 p.m. - 1 p.m. Pacific time.
  2. Wednesday, April 15, 2020, 7 a.m. - 8 a.m. Pacific time.
  3. Wednesday, April 15, 2020, 4 p.m. - 5 p.m. Pacific time.
  4. Thursday, April 16, 2020, 7 a.m. - 8 a.m. Pacific time.
  5. Thursday, April 16, 2020, 12 p.m. - 1 p.m. Pacific time.
  6. Wednesday, April 22, 2020, 7 a.m. - 8 a.m. Pacific time.
  7. Wednesday, April 22, 2020, 12 p.m. - 1 p.m. Pacific time.

How do I register?

You must pre-register for these webinars. Register at https://centene.zoom.us/webinar/register/3615861965700/WN_Ok9yL7LVQ_-azOaCl1bSBQ

At the end of the registration, you will be given the option to add the webinar to your calendar. The webinar has a call-in number, or you may listen to the audio broadcast through your computer. You may type questions as necessary. A copy of the presentation material will be distributed by email after the webinar.

COVID-19 Testing and Screening Billing Information

Updated 4/6/20 What billing codes should be used to bill for COVID-19 testing?

Starting April 1st, 2020, fee-for-service providers performing the COVID-19 test can begin billing Health Net for services that are Health Net's responsibility for payment that occurred after February 4, 2020, using the following newly created HCPCS and CPT codes:

  • HCPCS U0001 – For CDC developed tests only: 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • HCPCS U0002 – For all other commercially available tests: 2019-nCoV Real-Time RT-PCR Diagnostic Panel. (It is not yet clear if the Centers for Medicare & Medicaid Services (CMS) will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.)
  • CPT 87635 – Effective March 13, 2020 (the industry standard for reporting of novel coronavirus tests across the nation's health care system).

All member cost-share requirements (copayment, coinsurance and/or deductible amounts) related to the screening and testing for COVID-19 will be waived across all products.

  • Health Net will absorb the costs for waived copayments for COVID-19 screening and testing to support our network providers.

In addition to cost-share requirements, authorization requirements will be waived for any claim that is received with these specified codes.

Providers may bill the above codes regardless of provider type or contracting status.

What diagnosis codes should be used to bill for services related to COVID-19 screening and testing?

For complete and up-to-date diagnosis coding for COVID-19, visit the NCHS website.

The following diagnosis codes can be used to bill for screening and testing services related to COVID-19.

  • Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases.
  • Z03.818 – Encounter for observation for suspected exposure to other biological agents ruled out.

Is there more information available on COVID-19 billing?

For additional information on coding, refer to the following links from the American Medical Association (AMA):

What is the deadline to file claims?

The deadline to file claims for providers impacted by COVID-19 will be extended to 90 calendar days beyond standard filing timelines or the timeline in your Health Net Provider Participation Agreement (PPA). This also applies to Medi-Cal late filing penalties.

Can providers balance bill members for fees related to screening and testing for COVID-19?

Balance billing is strictly prohibited by state and federal law and Health Net's PPA. Providers may not bill members for any fees related to screening and testing for COVID-19.

COVID-19 Screening and Testing

Is Health Net requiring prior authorization, precertification, prior notification, or step therapy protocols for COVID-19 screening and testing?

Health Net is not requiring prior authorization, precertification, prior notification, or step therapy protocols for COVID-19 screening and testing services at this time.

Participating Physician Groups (PPGs) delegated by Health Net to authorize services related to COVID-19 screening and testing are required to ensure members receive the care they need as quickly as possible by not requiring prior authorization, precertification, prior notification, or step therapy protocols for COVID-19 screening and testing services at this time.

Updated 4/6/20 Is Health Net waiving cost-share requirements for screening and testing?

Health Net benefit plans cover screening and testing for COVID-19. Health Net is waiving all member cost-sharing requirements including, but not limited to, copayments, deductibles, or coinsurance for all medically necessary screening and testing for COVID-19, including hospital (including emergency department), urgent care visits, and provider office visits where the purpose of the visit is to be screened and/or tested for COVID-19.

Waived cost share for capitated physician groups' or IPAs' paid screening/testing services will be reimbursed by the health plan. Details regarding the process for capitated services to receive reimbursement for waived member cost shares will be released at a later date.

Updated 4/6/20 Where is COVID-19 testing available?

LabCorp, Quest Diagnostics™ and Bio Reference and several commercial and hospital based laboratories are currently offering testing for COVID-19. Providers are encouraged to visit the following sites for more information on registration and specimen collection requirements:

  • LabCorp – Physicians who send laboratory testing to LabCorp, will require an active account. Please contact LabCorp at 1-800-859-6046 and speak to a customer service representative to set up account.
  • Quest Diagnostics – website or call 1-866-697-8378. Providers can open an account.
  • BioReference – Providers do not need to sign up. Tests can be sent through courier or FedEx depending on area. Providers can open an account or contact BioReference via telephone at 1-833-684-0508 or 1-800-229-5227.
  • Twenty-two public health labs in California are testing samples for COVID-19. Providers can refer members for testing to their county's public health department found at www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/ncov2019.aspx. Additional information can also be found at the California Department of Public Health.
  • Providers can confirm with Community Hospitals to determine if they are offering testing for COVID-19.

Testing can be ordered only by physicians or other authorized health care providers.

  • Members seeking testing for COVID-19 should consult with their physician or health care provider who may order the test if they determine the patient meets testing criteria.

The Lab Patient Service Centers will not be collecting specimens for COVID-19 testing. DO NOT refer patients to Lab Patient Service Centers. Please contact specific labs for instructions for specimen collection and transport, and to obtain specimen collection supplies.

What are the screening and testing guidelines for COVID-19?

Refer to the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/coronavirus/2019-ncov/downloads/priority-testing-patients.pdf for updated guidelines for testing patients suspected of having the COVID-19 infection.

On March 19, 2020, the state of California launched a coronavirus awareness website. This site provides the following testing recommendations:

  • California is expanding the coronavirus testing capacity daily.
  • Currently, testing is being prioritized for people who:
    • Have the coronavirus symptoms AND
    • Have one of these risk factors:
      • Have had contact with a person who has tested positive for COVID-19, OR
      • Are health care providers or work with vulnerable populations (such as a long term care facility), OR
      • Traveled to an affected country in the past 14 days, OR
      • Are over age 60, have a compromised immune system or have serious chronic medical conditions
COVID-19 Related Treatments

Added 4/6/20 Is Health Net waiving cost-share requirements for COVID-19 related treatments?

Effective immediately, Health Net will waive member cost sharing for COVID-19 related treatments for all Medicare, Medi-Cal and commercial fully insured members.

Waived cost share for capitated physician groups' or IPAs' paid COVID-19 related treatments will be reimbursed by the health plan. Details regarding the process for capitated services to receive reimbursement for waived member cost shares will be released at a later date.

Added 4/6/20 Is Health Net waiving prior authorizations for COVID-19 related treatments?

Effective immediately, Health Net and its delegated entities will waive prior authorizations for COVID-19 related treatments for all Medicare, Medi-Cal and commercial fully insured members. Inpatient admission notification is still required as soon as possible to Health Net and the member's assigned delegated participating physician group (PPG) or IPA, if available.

Added 4/6/20 What COVID-19 ICD-10 diagnoses codes are approved for use?

  • B97.29: Confirmed cases - other coronavirus as the cause of diseases classified elsewhere (prior to 4/1/20)
  • U07.1: 2019-nCoV - Confirmed by lab testing (effective 4/1/20)
Prescription Information

How do members obtain an emergency supply of a prescription?

To obtain an emergency supply of a prescription medication, affected members can return to the pharmacy where the original prescription was filled. In addition, we are waiving prescription refill limits for medically necessary drugs and relaxing restrictions on home or mail delivery of prescription drugs. If the pharmacy is not open due to the state of emergency, affected members can contact the Emergency Response line at 1-800-400-8987, 8 a.m. to 6 p.m. Pacific Time (PT) for questions or assistance.

Coping Assistance for Members

Is coping assistance offered to members impacted by COVID-19?

Members impacted by COVID-19 may contact MHN, our behavioral health subsidiary, for referrals to mental health counselors, local resources or telephonic consultations to help them cope with stress, grief, loss, or other trauma resulting from COVID-19. For the duration of the COVID-19 public health emergency period and its immediate aftermath, affected members may contact MHN 24 hours a day, seven days a week at 1-800-227-1060, or the telephone number listed on the member's identification (ID) card.

Reporting COVID-19 Impacts to Offices and Facilities

Updated 4/6/20 What if my office or facility is impacted by COVID-19?

If your office or facility is impacted by COVID-19 and this affects your ability or capacity to provide services and access to members, please contact your provider network regional representative immediately. If you are affiliated with a participating physician group (PPG) or independent physician association (IPA), please contact your PPG of IPA immediately. Health Net contracted PPGs must notify their Health Net designated network representative of any changes in access to their provider panel.

As a reminder, providers are responsible to provide coverage to their patients, and to communicate this to patients via appropriate signage, messaging, and communications. We encourage the use of telehealth services to promote physical distancing while supporting the needs of your patients, whenever possible. The use of urgent care or emergency room/department services to provide routine coverage for your office is not appropriate, unless the use of emergency room/department services are medically necessary.

If you close your office, or if you switch to only providing virtual appointments, take the following action:

  1. Contact your Health Net provider network regional representative immediately.
  2. Notify your patients who have upcoming appointments about your office changes and provide documentation of how your patients were notified to your Health Net designated network representative.
  3. Inform your patients about available coverage options for your office, including voicemail instructions and/or message for patients, posters and member outreach.
Websites with Information and Guidance on COVID-19

Where can I obtain the latest information and guidance on COVID-19?

To obtain the latest updates and guidance on assisting patients and when to take action, visit provider.healthnet.com where you will see a link to Health Net Alerts: COVID-19 in the yellow bar. You can also visit the websites below for more information about COVID-19 and the latest guidance from public health officials:

Additional Information, Requirments and Guidance

  • All participating providers must continue to provide health care services and perform delegated functions. However, the CDC, CMS and other health authorities recommend delaying elective inpatient and outpatient surgical and procedural cases. The delay of elective surgeries or other non-urgent procedures during this time is allowed and is recommended by CMS. The referring or treating provider must have determined and noted in the relevant record that when considering COVID-19 implications during this public health emergency period, a longer waiting time will not have a detrimental impact on the health of the member.
  • Telehealth services during this emergency period may be used to determine medical necessity for someone to come into the office, emergency room or urgent care center. Refer to the TELEHEALTH section above for more information.
  • For Commercial and Medi-Cal, where mailing hard-copy notices to members and providers as required by law is delayed due to personnel shortages and/or safety precautions enacted, please contact the member or provider electronically or by telephone. If the provider or PPG, as the case may be, does not have personnel available to mail hard-copy information, it is sufficient to communicate with members and providers electronically and/or by telephone, so long as a log or record of such communications is maintained. (Note: CMS has not yet communicated a similar relaxation of its regulatory requirements for Medicare Advantage.)
  • Health care workers, including those supporting healthcare operations, are considered essential workers and are exempt from the "stay at home," "shelter in place," and "shelter at home" recommendations and orders recently announced.
  • Added 4/6/20 Los Angeles County providers can refer to publichealth.lacounty.gov/eprp/lahan/alerts/LAHANCOVID032520.pdf to access the Los Angeles County Department of Public Health's alert regarding Preserving Critical Supplies and Resources.

3/17/20

Provider Update


3/7/20

Health Net Assisting Members in California During State of Emergency

In response to Gov. Gavin Newsom's declared state of emergency, Health Net, LLC wants to help ensure everyone is informed about what they can do to help protect themselves from the coronavirus (COVID-19).


3/5/20

What you need to know about COVID-19 (updated, 3/20/20)

Coronavirus Disease 2019 (COVID-19) is a new disease that causes respiratory illness in people and can spread from person to person. Though the risk of getting COVID-19 in the U.S. is low, learn how you can help keep yourself and others healthy.

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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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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.

Upload No Review - Terms of Use

I have elected to upload a zipped folder of care coordination documents in a pdf format using the specified file naming convention as set forth below. I understand the importance of ensuring that the file names are accurate and that they accurately identify the member(s) that the care coordination document(s) is/are associated with. I elected to upload the attached documentation and confirm submission without utilizing the review option because the files were generated and named systematically, not manually, and/or the files have been carefully audited and confirmed to be accurately named. By confirming my upload, I am representing that the file(s) is/are named accurately.


Document Type - File naming convention
PPG Care Plans - careplan_hnsubidpersonid_yyyymmdd.pdf
CBAS Care Plan - cbascp_hnsubidpersonid_yyyymmdd.pdf
CBAS Assessment - cbasa_hnsubidpersonid_yyyymmdd.pdf
MSSP Assessment - msspa_hnsubidpersonid_yyyymmdd.pdf
MSSP Care Plan - msspcp_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Assessment - mctna_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Care Plan - mctncp_hnsubidpersonid_yyyymmdd.pdf
SNF MDS Form - snfmds_hnsubidpersonid_yyyymmdd.pdf
Note: hnsubidpersonid is the Health Net Subscriber ID and Person ID
File name example: careplan_R9999999900_20140505.pdf

Upload & Review - Terms of Use

I have elected to upload a zipped folder of care coordination documents in a pdf format using the specified file naming convention as set forth below. I understand the importance of ensuring that the file names are accurate and that they accurately identify the member(s) that the care coordination document(s) is/are associated with. I have elect to upload of the attached documents and confirm submission using the review option. I certify that the files will be carefully audited and confirmed to be accurately named before confirming my upload. By confirming my upload, I am representing that the file(s) is/are named accurately.


Document Type - File naming convention
PPG Care Plans - careplan_hnsubidpersonid_yyyymmdd.pdf
CBAS Care Plan - cbascp_hnsubidpersonid_yyyymmdd.pdf
CBAS Assessment - cbasa_hnsubidpersonid_yyyymmdd.pdf
MSSP Assessment - msspa_hnsubidpersonid_yyyymmdd.pdf
MSSP Care Plan - msspcp_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Assessment - mctna_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Care Plan - mctncp_hnsubidpersonid_yyyymmdd.pdf
SNF MDS Form - snfmds_hnsubidpersonid_yyyymmdd.pdf
Note: hnsubidpersonid is the Health Net Subscriber ID and Person ID
File name example: careplan_R9999999900_20140505.pdf

Terms of Use for 1 to 10 Individual Documents Upload

I have elected to upload a group of individual files by identifying and attaching up to 10 individual files. I understand that the files will be named based on the information I enter for each file and that the file name will identify the member that the care coordination document(s) is/are associated with. Additionally, I understand the importance of ensuring that the file(s) is/are named correctly. I certify that the files will be carefully audited and confirmed to be accurately named before confirming my upload. By confirming my upload, I am representing that the file(s) is/are named accurately.


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Your files are being uploaded. If you click to another page or close your browser, the upload process may be cancelled.


Once the upload process is complete, you will be redirected to a confirmation page.

Care Coordination Download Terms of use

I am requesting to download care coordination documents on behalf of the Medical Group that I/we represent and the affiliated groups and entities. Furthermore, I understand that the files that I am requesting to download contain Protected Health Information ("PHI"), and that must be protected and only made available to affiliated Covered Entities for health care operational purposes consistent with 45 C.F.R. 164.501 and 506(c) and health care providers as defined by the Health Insurance Portability and Accountability Act ("HIPAA") that I/we have a treatment relationship with the patient(s).


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Your request to download Encounter Records information has been received. Health Net will send you an email to within the next 24 hours with a link to download the requested information in a comma delimited (.csv) format.


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