The following policies and procedures apply to provider claims for services that are adjudicated by Health Net of California, Health Net Life Insurance Company, and Health Net Community Solutions "Health Net", except where otherwise noted.
Purpose: Beneficiaries who are transitioning from fee-for-service into a managed care plan have the right to request continuity of care, such as completion of care from current providers in accordance with the state law and the health plan contracts, with some exceptions. All managed care plan beneficiaries with pre-existing provider relationships who make a continuity of care request must be given the opportunity to request coverage of continued treatment for up to 12 months with the out-of-network provider.
Health Net requires that providers confirm eligibility as close as possible to the date of the scheduled service. Due to ongoing changes in eligibility, the best practice is to confirm eligibility no more than one day prior to providing a prior-authorized service.
To verify eligibility, providers should either:
Line of Business | Telephone Number | Email Address |
---|---|---|
HMO/POS/HSP, PPO, Centene Corporation Employee Self-Insured PPO PLAN, & EPO | provider_services@healthnet.com | |
Medicare programs | 1-800-929-9224 | |
Covered California | 1-888-926-2164 | |
Medi-Cal | 1-800-675-6110 | N/A |
Cal MediConnect – Los Angeles County | 1-855-464-3571 | provider_services@healthnet.com |
Cal MediConnect – San Diego County | 1-855-464-3572 |
This information pertains to claims for services rendered by providers to Health Net members in all products offered by Health Net. Note: where contract terms apply, not all of this information may be applicable to claims submitted by Health Net participating providers.
Health Net will process claims received within 365 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 prefers that all claims be submitted electronically. Refer to electronic claims submission for more information.
For providers unable to send claims electronically, paper claims are accepted if on the proper type of form. Requirements for paper forms are described below.
Health Net only accepts standard claim forms printed in Flint OCR Red, J6983 (or exact match) ink. Paper claim forms must be typed in black ink with either 10 or 12 point Times New Roman font, and on the required original red and white version to ensure clean acceptance and processing. Claims submitted on black and white, handwritten or nonstandard forms will be rejected and a letter will be sent to the provider indicating the reason for rejection. These claims will not be returned to the provider. To reduce document handling time, providers must not use highlights, italics, bold text, or staples for multiple page submissions. Copies of the form cannot be used for submission of claims, since a copy may not accurately replicate the scale and OCR color of the form. Health Net does not supply claim forms to providers. Providers should purchase these forms from a supplier of their choice.
Providers billing for professional services and medical suppliers must complete the CMS-1500 (02/12) form. The form must be completed in accordance with the guidelines in the National Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual Version 5.0 7/17 at www.nubc.org. Paper claims follow the same editing logic as electronic claims and will be rejected with a letter sent to the provider indicating the reason for rejection if non-compliant. These claims will not be returned to the provider.
Providers billing for institutional services must complete the CMS-1450 (UB-04) form. The form must be completed in accordance with the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual 2018 at www.nubc.org. Paper claims follow the same editing logic as electronic claims and will be rejected with a letter sent to the provider indicating the reason for rejection if non-compliant. These claims will not be returned to the provider. Medicare CMS-1500 and CMS-1450 completion and coding instructions, are available on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov.
All paper claims and supporting information must be submitted to:
Line of Business | Address |
---|---|
Commercial | Health Net Commercial Claims P.O. Box 9040 Farmington, MO 63640-9040 |
Medi-Cal | Health Net Medi-Cal Claims PO Box 9020 Farmington, MO 63640-9020 |
Salud con Health Net | Health Net Commercial Claims P.O. Box 9040 Farmington, MO 63640-9040 |
Medicare Advantage | Health Net Medicare Claims PO Box 9030 Farmington, MO 63640-9030 |
A complete claim is a claim, or portion of a claim that is submitted on a complete format adopted by the National Uniform Billing Committee and which includes attachments and supplemental information or documentation that provide reasonably relevant information or information necessary to determine payer liability.
IMPORTANT NOTE: We require that all facility claims be billed on the UB-04 form.
Health Net uses the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual as the standard source for codes and code descriptions to be entered in the various form locators (FL). National Uniform Billing Committee’s UB-04 Data Specifications Manual, is available at www.nubc.org.
CODING
Correct coding is key to submitting valid claims. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available.
Diagnosis Coding
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), is currently used to code diagnostic information on claims. Multiple entities publish ICD-10-CM manuals and the full ICD-10-CM is available for purchase from the AMA bookstore on the Internet.
Procedure Coding
Use Healthcare Common Procedure Coding System (HCPCS) Level I and II codes to indicate procedures on all claims, except for inpatient hospitals. ICD-10-CM codes are used for procedure coding on inpatient hospital Part A claims.
For all other uses, Level I Current Procedural Terminology (CPT-4) codes describe medical procedures and professional services. CPT is a numeric coding system maintained by the AMA. The CPT code book is available from the AMA bookstore on the Internet.
Mandatory Items for Claims Submission
All professional and institutional claims require the following mandatory items:
This is not meant to be a fully inclusive list of claim form elements. Additional fields may be required, depending on the type of claim, line of business and/or state regulatory submission guidelines.
To avoid possible denial or delay in processing, the above information must be correct and complete.
The following providers must include additional information as outlined:
Non-participating providers are expected to comply with standard coding practices. Health Net uses code auditing software to improve accuracy and efficiency in claims processing, payment, and reporting. The software detects and documents coding errors on provider claims prior to payment by analyzing CPT/HCPCS, ICD-10, modifiers and place of service codes against correct coding guidelines. The following sources are utilized in determining correct coding guidelines:
Health Net may request medical records or other documentation to verify that all procedures/services billed are properly supported in accordance with correct coding guidelines.
Specific Billing Requirements
The following are billing requirements for specific services and procedures.
Non-Hospital Substance Abuse Facilities (Residential Treatment, Intensive Outpatient, Partial Hospitalization Facilities)
Vaccines for Children Program Billing Procedures
Participating providers must submit claims to Health Net for Vaccines for Children (VFC) program-supplied immunizations to receive reimbursement for the administration of the immunization administration CPT code and the associated VFC vaccine CPT code when requesting payment for the administration fee of VFC vaccines.
For each immunization administered, the claim must include:
Providers billing electronically must submit administration and vaccine codes on one claim form. Multiple claims should not be submitted.
Providers submitting multiple CMS-1500 successor forms must staple the completed forms together and number the pages appropriately.
Although the provider is receiving the vaccines from the VFC program, the charge amount for the actual vaccine CPT code must reflect a provider’s usual and customary charge for the vaccine on claims submitted to Health Net.
Use of modifier SL sufficiently identifies the claim as a state-supplied vaccine for which the billed vaccine charge is not reimbursed. Using modifier SL ensures that the claim is processed, the provider is reimbursed for the administration fee and the vaccination is included in performance measurements.
These billing procedures are designed to standardize billing practices and eliminate erroneous payments for state-supplied vaccines, which necessitate collection of overpayments from providers. Health Net may seek reimbursement of amounts that were paid inappropriately
Failure to bill VFC claims in accordance with the billing procedures noted above results in denials for both the vaccine and the associated administration. For all questions, contact the applicable Provider Services Center.
Line of Business | Telephone Number | Email Address |
---|---|---|
HMO/POS/HSP, PPO, Centene Corporation Employee Self-Insured PPO PLAN, & EPO | provider_services@healthnet.com | |
Medicare programs | 1-800-929-9224 | |
Covered California | 1-888-926-2164 | |
Medi-Cal | 1-800-675-6110 | N/A |
Cal MediConnect – Los Angeles County | 1-855-464-3571 | provider_services@healthnet.com |
Cal MediConnect – San Diego County | 1-855-464-3572 |
Health Net acknowledges electronically submitted claims, whether or not the claims are complete, within two business days via a 277CA to the clearinghouse following receipt. Health Net acknowledges paper claims within 15 business days following receipt for HMO, Point of Service (POS)and Medi-Cal claims and within 15 calendar days for PPO, EPO, and Flex Net claims. If a paper claim is paid or denied within 15 days, the Remittance Advice (RA) is the acknowledgment of claims receipt. A provider may obtain an acknowledgment of claim receipt in the following manner:
Claims received from a provider's clearinghouse are acknowledged directly to the clearinghouse in the same manner and time frames noted above.
Date of receipt
Date of receipt is the business day when a claim is first delivered, electronically or physically, to Health Net's designated address for submission of the claim depending upon the line of business (see Submission of Claims section).
Health Net reimburses each complete claim, or portion thereof, from a provider of service no later than:
This time frame begins after receipt of the claim unless the claim is contested or denied. Health Net reserves the right to adjudicate claims using reasonable payment policies and non-standard coding methodologies. These policies and methodologies are consistent with available standards accepted by nationally recognized medical organizations, federal regulatory bodies and major credentialing organizations.
Hospitals submitting inpatient acute care claims for Health Net Medi-Cal members:
Health Net notifies the provider of service in writing of a denied or contested HMO, POS, HSP, and Medi-Cal claim no later than 45 business days after receipt of the claim. PPO, EPO, and Flex Net claims are denied or contested within 30 business days.
Date of contest or date of denial is the electronic mark or postmark date indicating the date when the contest or denial was transmitted electronically or mailed by U.S. mail.
A contested claim is one that Health Net cannot adjudicate or accurately determine liability because more information is needed from either the provider, the claimant or a third party.
Incomplete claims or claims that require additional information are contested in writing by Health Net in the form of an Explanation of Payment/Remittance Advice (EOP/RA), which may in some circumstances be followed by additional written communication within the timeframes noted above. If Health Net needs additional information before the claim can be adjudicated, the necessary information must be submitted within 365 days of the date of the EOP/RA that reflects the contested claim, in order to have the claim considered by Health Net.
The EOP/RA for each claim, if wholly or partially denied or contested, includes an explanation of why Health Net made its determination. Supplemental notices describing the missing information needed is sent to the provider within 24 hours of a determination to contest the claim.
Each EOP/RA includes instructions on how to submit the required information in order to complete the claim if Health Net has contested it. Each EOP/RA reflecting a denied, adjusted or contested claim includes instructions on the department to contact for general inquiries or how to file a provider dispute, including the procedures for obtaining provider dispute forms and the mailing address for submission of the dispute.
HMO, POS, HSP and Medi-Cal Claims:
Late payments on complete HMO, POS, HSP or Medi-Cal claims that are neither contested nor denied automatically include interest at the rate of 15 percent per year for the period of time that the payment is late.
The late payment on a complete HMO, POS, HSP, or Medi-Cal claim for emergency room (ER) services that is neither contested nor denied automatically includes the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at 15 percent per year for the period of time that the payment is late.
If Health Net does not automatically include the interest fee with a late-paid complete HMO, POS, HSP, or Medi-Cal claim, an additional $10 is sent to the provider of service.
PPO, EPO, and Flex Net Claims:
Late payments on complete PPO, EPO or Flex Net claims that are neither contested nor denied automatically include interest at the rate of 10 percent per year beginning with the first calendar day after the 30-business-day period subject to exceptions pursuant to applicable state law including fraud, misrepresentation, eligibility determinations, or instances in which the carrier has not been granted reasonable access to information under a provider's control.
The late payment on a complete PPO, EPO or Flex Net claim for ER services that is neither contested nor denied automatically includes the greater of $15 per year or interest at the rate of 10 percent per year beginning with the first calendar day after the 30-business-day period.
The Health Net Provider Services Department is available to assist with overpayment inquiries. A provider who has identified an overpayment should send a refund with supporting documentation to:
California Recoveries Address:
Health Net Overpayment Recovery Department
Claims Refunds
File #56527
Los Angeles, CA 90074-6527
If Health Net identifies an overpayment due to a processing error, coordination of benefits, subrogation, member eligibility, or other reasons, a notice is sent that includes the following:
Failure to comply with timely filing guidelines when overpayment situations are the result of another carrier being responsible does not release the provider from liability.
If the overpayment request is not contested by the provider, and Health Net does not receive a full refund or an agreed-upon satisfactory repayment amount within 45 days from the date of the overpayment notification, a withhold in the amount of the overpayment may be placed on future claim payments.
Whenever possible, Health Net strives to informally resolve issues raised by providers at the time of the initial contact. If an issue cannot be resolved informally by a customer contact associate, Health Net offers its nonparticipating providers a dispute and appeal process.
Health Net is a Medicare Advantage organization and as such, is regulated by the Centers for Medicare & Medicaid Services (CMS). In accordance with CMS regulations, providers who are not contracted with a Medicare Advantage organization may file a standard appeal for a claim that has been denied, in whole or in part, but only if they submit a completed Waiver of Liability Statement (pdf). If you complete a Waiver of Liability Statement, you waive the right to collect payment from the member, with the exception of any applicable cost sharing, regardless of the determination made on the appeal.
If you appeal and we uphold the denial, in whole or in part, you will have additional appeal rights available to you including, but not limited to, reconsideration by a CMS contracted independent review entity.
To appeal, mail your request and completed Waiver of Liability Statement (pdf) within 60 calendar days after the date of the Notice of Denial of Payment to:
Health Net Medicare – Appeals
P.O. Box 9030
Farmington, MO 63640-9030
If you believe that the payment amount you received for a service you provided to a Health Net Medicare Advantage member is less than the amount paid by Original Medicare, you have the right to dispute the payment amount by following the payment dispute resolution process. Nonparticipating provider claim payment disputes also include instances where you disagree with the decision to pay for a different service or level than billed. Some reasons for payment disputes are:
Submit your dispute request, along with complete documentation (such as a remittance advice from a Medicare carrier), to support your payment dispute. Claims must be disputed within 120 days from the date of the initial payment decision.
Submit your dispute in writing to:
Health Net Medicare – AppealsHealth Net will review your dispute and respond to you with a payment review determination decision within 30 days from the time we receive your dispute. If we agree with your position, we will pay you the correct amount, including any interest that is due. We will inform you in writing if we deny your payment dispute. If you still disagree with the decision, you may request a second-level dispute with Health Net within 180 calendar days of receipt of the initial decision notice.
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