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Balance Billing

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
    (does not apply to HSP)
  • Hospitals
  • Ancillary

Balance billing is strictly prohibited by state and federal law and Health Net's Provider Participation Agreement (PPA).

Balance billing occurs when a participating provider bills a member for fees and surcharges above and beyond a member's copayment and coinsurance responsibilities for services covered under a member's benefit program, or for claims for such services denied by Health Net or the affiliated participating physician group (PPG). Participating providers are also prohibited from initiating or threatening to initiate a collection action against a member for non-payment of a claim for covered services. Participating providers agree to accept Health Net's fee for these services as payment in full, except for applicable copayments, coinsurance, or deductibles.

Cal MediConnect members are not subject to copayments, so providers must not charge Cal MediConnect members coinsurance, copayments, deductibles, financial penalties, or any other amount. Providers can refer to the Verifying and Clearing Share-of-Cost section for information regarding Cal MediConnect members' share of cost (SOC) responsibility for certain services. Additionally, Cal MediConnect members may contact the Cal MediConnect Member Services Center to determine which prescription medications may be subject to a copayment from the member. 

Participating providers may bill a member for non-covered services when the member is notified in advance that the services to be provided are not covered and the member, nonetheless, requests in writing that the services be rendered. A participating provider who exhibits a pattern and practice of billing members will be contacted by Health Net and is subject to disciplinary action.

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Last Updated: 11/11/2019