Non-Participating Provider Policies

Continuity of Care Request Forms – for Members

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.

• Medi-Cal
• Cal MediConnect

Eligibility Verification

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:

1. Use the EDI Eligibility Benefit Inquiry and Response – this electronic transaction facilitates the verification of a member's eligibility and benefit information without the inconvenience of a phone call. Your clearinghouse should be able to assist with sending Health Net an electronic eligibility inquiry.
2. Contact the applicable Health Net Provider Services Center at:

Claims Settlement and Dispute Resolution Mechanism
(AB 1455, SB 367 and SB 634)

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.

Timely Filing of Claims

Health Net will process claims received within 180 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.

Claims Submission

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. 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. 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.

All paper claims and supporting information must be submitted to:

Complete Claim Definition

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 here.

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.

Claims Submission Instructions

Mandatory Items for Claims Submission

All professional and institutional claims require the following mandatory items:

• Appropriate type of insurance coverage (box 1 of the CMS-1500).
• Billing provider tax identification number (TIN), address and phone number.
• Billing provider National Provider Identifier (NPI).
• Bill type (institutional) and/or place of service (professional).
  • Original submission is indicated with a 1 in claim frequency box or resubmission code (box 22).
  • Codes 7 and 8 should be used to indicate a corrected, void or replacement claim and must include the original claim ID.
• Patient name, Health Net identification (ID) number, address, sex, and date of birth must be included. If the subscriber is also the patient, only the subscriber data needs to be submitted. If different, then submit both subscriber and patient information.
• Other health insurance information and other payer payment, if applicable.
• Patient or subscriber medical release signature/authorization.
• Accept assignment (box 13 of the CMS-1500).
• Referring provider name and NPI.
• Check if lab work was performed outside the physician's office and indicate charges by the lab (box 20 on CMS-1500).
• Rendering/attending provider NPI (only if it differs from the billing provider) and authorized signature.
• Primary diagnosis code and all additional diagnosis codes (up to 12 for professional; up to 24 for institutional) with the proper ICD indicator (only ICD 10 codes are applicable for claims with dates of service on and after October 1, 2015).
• Diagnosis pointers are required on professional claims and up to four can be accepted per service line.
• Diagnosis codes, revenue codes, CPT, HCPCS, modifiers, or HIPPS codes that are current and active for the date of service. Claims with incomplete coding or having expired codes will be contested as invalid or incomplete claims.
• Authorization, if applicable, should be sent in the 2300 Loop, REF segment with a G1 qualifier for electronic claims (box 23 for CMS-1500 or box 63 for UB-04).
• Referral information, if applicable.
• Inpatient institutional claims must include admit date and hour and discharge hour (where appropriate), as well as any Present on Admission (POA) indicators, if applicable.
• Inpatient professional claims must include admit and discharge dates of hospitalization.
• Admission type code for inpatient claims.
• Admitting diagnosis required for inpatient claims.
• Outpatient claims must include a reason for visit.
• Statement from and through dates for inpatient.
• Service line date required for professional and outpatient procedures.
• National Drug Code (NDC) for drug claims as required.
• Universal product number (UPN) codes as required.
• Accommodation code is submitted in Value Code field with qualifier 24, if applicable.
• Share of cost is submitted in Value Code field with qualifier 23, if applicable.
• Charges for listed services and total charges for the claim.
• Days or units.
• Early Periodic Screening, Diagnosis, and Treatment (EPSDT)/family planning indicators (box 24 in CMS-1500).
• Name and address of service location.

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:

• Emergency services providers: The claim must include a legible emergency department report and any state-designated data requirements included in statutes or regulations.
• Dentists and other professionals providing dental services: The form and data set approved by the American Dental Association (ADA), Current Dental Terminology (CDT) codes and modifiers, and any state-designated data requirements included in statutes or regulations. When services are authorized as a medical benefit, the provider should indicate ”medical necessity” on the claim form to ensure proper routing.
• Non-primary care providers: The first and last name of the referring physician and the referral number given by the referring physician or participating physician group (PPG) (include state license number if available). The only exceptions are anesthesia and assistant surgeon claims described in Specific Billing Requirements.
• On-call physicians: Where applicable, physicians who are on call for a primary care physician (PCP) do not require a referral. The name of the PCP should be noted on the claim in box 19 or 23 on the CMS-1500 claim form. For self-referrals the provider should indicate Self-Referred in box 17 of the CMS-1500.
• Providers not specified: A properly completed paper or electronic billing instrument submitted in accordance with Health Net's specifications and any state-designated data requirements included in statutes or regulations.

Paper Claims Submission Rejections and Resolutions

• Medical Paper Claims Submission Rejections and Resolutions (PDF)
• Medical Paper Claims Submission Rejections and Resolutions – CalViva (PDF)
• Medical Paper Claims Submission Rejections and Resolutions – Cal MediConnect (PDF)

Claims Coding Practice

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:

• Centers for Medicare & Medicaid Services (including NCCI, MUE, and Claims Processing Manual guidelines)
• Public domain specialty provider associations (such as American College of Surgeons, American Academy of Orthopaedic Surgeons, etc.)
• State provider manuals and fee schedules
• American Medical Association (CPT, HCPCS, and ICD-10 publications)
• Health plan policies and provider contract considerations
• Clinical consultants who research, document, and provide edit recommendations based on the most common clinical scenario.
• In addition to nationally-recognized coding guidelines, the software has flexibility to allow business rules that are unique to the needs of individual product lines

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.

• All Services: Prior authorizations are required for all non-contracting provider claims except in certain emergent situations. A request for authorization must be made via telephone to Health Net's hospital Notification Unit at 1-800-995-7890 Option 1.
• Allergy injections: Specify type of injections provided in box 24D of the CMS-1500 form.
• Ambulance claim: Trip reports are not needed for the following claims:
  • 911 referral
  • Law enforcement or fire department involvement
  • Mental health hold (5150/5350)
  • Motor vehicle accident (MVA)
  • PCP request/referral
• Ambulatory/outpatient surgery claim: If implantable devices are included on the claim, one of the following must be submitted for each implant billed on the claim form:
  • Copy of the manufacturer's invoice; or
  • Copy of the medical record's implant log
• Anesthesia claim: Include surgeon's name and license number instead of the referring physician's name. For a cesarean section performed after epidural anesthesia, indicate administration time for the general anesthetic and the epidural separately on the claim. The unit field should contain the number of time units (not minutes) being charged. Do not include base value or modifier units.
• Antigen injections: Specify the type of antigen given by using appropriate HCPCS code. Antigens are reimbursed separately.
• Assistant surgeon: Include surgeon's name in box 17 of the CMS-1500. Use modifier -80 after CPT code for a physician. Use modifier -AS after CPT code for non-physician.
• Coordination of benefits (COB): When Health Net is the secondary payer; the provider must submit the claim and a copy of the Explanation of Medicare Benefits/Explanation of Benefits (EOMB/EOB) from the primary carrier to Health Net for payment consideration.
• Drug testing – Dates of service on and after January 1, 2017: Health Net follows the Centers for Medicare & Medicaid Services (CMS) coding guidelines for reporting drug testing procedures as outlined in the 2017 CMS Clinical Laboratory Fee Schedule (CLFS) Final Determinations document posted on the CMS website (CMS8). A maximum of one definitive test may be billed per week, and one presumptive test may be billed per day with a maximum of three per week.
  • Presumptive drug testing codes 80305, 80306, and 80307
  • Definitive drug testing codes G0480, G0481, G0482, and G0659
• Eye exams: Claims for exams related to diseases or injuries of the eye must
  include diagnosis.
• Injectable medications: When billing for injectable medications, list appropriate HCPCS code identifying medication name, NDC number, strength, dosage, and method of administration.
• Itemized OB care: State reason why a global maternity fee is not being billed.
• Lab collection fee: A collection and handling fee may only be billed for laboratory work sent to an outside laboratory. The name of outside laboratory and tests performed must be entered on claim form.
• Multiple diagnoses: Indicate specific diagnosis for each procedure billed.
• Sigmoidoscopy: Claims must include the length of the exam in centimeters. If the exam is over 35 centimeters, include modifier -22 (no report is required).
• Trauma: When billing a claim or itemization that is stamped trauma or with revenue code 208, an emergency room (ER) and Trauma Team Activation sheet/report must be attached to the claim.

Non-Hospital Substance Abuse Facilities (Residential Treatment, Intensive Outpatient, Partial Hospitalization Facilities)

• Bill on a UB-04 form
  Consolidated Billing – All charges for the patient stay should be included on the same bill, this includes therapy, treatment and ancillary services. Do not split bills by type of service or submit separate bills for overlapping dates of service for a component of treatment, including substance abuse toxicology testing.
• Type of bill – Enter the appropriate three- or four-digit code that indicates the type of bill you are submitting. The type of bill code used must correspond to the facility, Medicare certification and state license held by the billing entity.
• Revenue code – Enter the appropriate four-digit code that identifies the specific accommodation and specific ancillary services billed. Bills should use revenue codes to indicate the accommodation code and the specific therapy and ancillary services provided on each date of service. For outpatient programs, there must be date specific and, line item specific detail on the bill, meaning, that each therapy service on each date of service must be documented with the appropriate revenue code. Additionally, revenue codes used should correspond to the facility Medicare Certification and state license.
• Procedure code – Enter the appropriate HCPCS procedure code. All claims must specify the corresponding ancillary or therapy service provided to the patient on each day of service. This should include the number of units provided on each date of service
• Itemization – There must be a single line item date of service for every revenue code on all bills. If a particular service is rendered five times during the billing period, the revenue code and HCPCS code must be entered five times, once for each service date. The provider's billed charges for each component of the claim should be listed separately, for example, the charges must identify the accommodation charges (where applicable) and the charge for each therapy.
• Non-covered services – These must be identified using revenue code 099X. Include a description of the non-covered service and the corresponding charge for that service. Non-covered services include, peer-led groups, such as AA meetings, and other items, such as massage therapy, surfing, gym, or exercise activities, and luxury facility items, such as fine linens, hot tubs, whirl pool bath tubs, and private rooms.
• 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:

• Vaccine CPT code with the modifier SL (indicating a state-supplied vaccine)
• Usual and customary charge
• Administration CPT code with modifier SL

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 or by email.

Acknowledgment of Claims

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:

• HMO, POS, HSP, PPO, EPO, and Flex Net Program claims: Electronic fax-back confirmation of claims receipt through the Provider Services Center interactive voice response (IVR) system and via a paper acknowledgment report mailed within 15 business days of claim receipt.
• Medi-Cal claims: Confirmation of claims receipt by calling the Medi-Cal Provider Services Center at 1-800-675-6110.

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).

Reimbursement of Claims

Health Net reimburses each complete claim, or portion thereof, from a provider of service no later than:

• 30 business days for PPO, EPO and Flex Net plans
• 45 business days for Medi-Cal plans
• 45 business days for HMO, POS, and HSP plans

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 uses an All Patient Refined Diagnosis Related Groups (APR DRG) pricing methodology that is consistent with Department of Health Care Services (DHCS) implemented Version 29 of APR DRG pricer.
• Health Net is aware that some hospitals may submit inpatient claims with anticipated APR DRG code and anticipated reimbursement on a claim form; however, Health Net reserves the right to assign the APR DRG for pricing and payment.

Denied or Contested Claims

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.

Interest on Late Payment of Claims

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.

Overpayment of Claims

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:

• Member's name and ID number
• Provider's account number
• Date of service
• Amount of overpayment
• Health Net's payment date
• Detailed reason for the refund request

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.

Provider Dispute

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.

Provider Dispute Resolution Process

Medicare Non-contracted Provider Appeals (Waiver of Liability)

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

Medicare Advantage Non-Participating Provider Disputes

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:

• Bundling issues
• DRG payments
• Downcoding

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 – Appeals
P.O. Box 9030
Farmington, MO 63640-9030

Health 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.