Explanation of Check

Providers receive an explanation of check each time a claim is processed. The following information correlates to the numbers on the sample explanation of check:

1. Number used by Health Net for internal purposes only
2. Page - Page number
3. Checking Acct.- Number used by Health Net for internal purposes only
4. Service Area - Service area identifying the geographical location of the provider rendering service
5. Remit - Number used by Health Net for tracking purposes
6. Check Number - Check number
7. Provider Name - Name of the PPG or facility to whom payment is made
8. T.I.N. - Provider's tax identification number
9. Check Date - Date check was issued
10. Claim Number - Unique number assigned to the claim

1. Beginning date of service
2. DOS End - Ending date of service
3. Revenue/CPT Code - Revenue/CPT code for service rendered
4. Serv. Units - Units of service provided
5. Billed Amount - Amount provider billed
6. Allowed Amount - Health Net's allowed amount for services rendered. This amount is determined after Medicare's payment is taken into consideration
7. Expl. Code - Code identifying the action that was taken on a particular detail line
8. Patient Liability - Copayment, deductible, or cost share owed by the member. Includes any non-covered charges that are the member's responsibility
9. OHI - Other health insurance payment
10. Net Payable - Amount paid on the claim after the completion of all calculations
11. Servicing Provider - Name of provider who rendered services
12. Provider License Number - License number of provider who rendered services
13. Patient Name - Name of member
14. Subscriber Name - For Medi-Cal, subscriber name is member name
15. Emp. Group ID - Medi-Cal members have group numbers that correspond to Health Net's Medi-Cal plan codes
16. Patient ID - Member's Health Net identification number
17. Patient Acct No - Account number assigned to patient by provider
18. LOB: Member Line of Business - ML - Medi-Cal
19. Patient Totals - Total of all services for member
20. Provider Totals - Total amount paid to servicing provider
21. Affiliate Totals - Total amount paid to group
22. Provider Totals - Total amount paid to servicing provider
23. Affiliate Totals - Total amount paid to group

1. For Medi-Cal, subscriber name is member name
2. Emp. Group ID - Medi-Cal members have group numbers that correspond to Health Net's Medi-Cal Plan codes
3. Patient ID - Member's Health Net identification number
4. Patient Acct No - Account number assigned to patient by provider
5. LOB: Member Line of Business - ML - Medi-Cal
6. Patient Totals - Total of all services for member
7. Provider Totals - Total amount paid to servicing provider
8. Affiliate Totals - Total amount paid to group
9. Provider Totals - Total amount paid to servicing provider
10. Affiliate Totals - Total amount paid to group
11. Explanation of Check Code - Written explanation for explanation code reflected on detail line
12. Begin Recoupment Balance - Negative balance carried forward from previous adjustments. This is money owed to the plan by the provider
13. Current Cycle Recoupment - New deductions incurred on this explanation of check
14. Amount Recouped This Cycle - Amount deducted from funds available this payment
15. New Recoupment Balance - Negative balance amount carried over that is deducted from the next and/or subsequent payments
16. Payee - Provider or PPG receiving payment for services
17. Payee ID -Tax identification number of provider or PPG receiving payment