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Claims Denial Requirements

Provider Type

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

Delegated participating providers and capitated hospitals are required to notify the provider when a claim is denied. The denial notice must contain the following elements:

  • Date of denial notice
  • Member name
  • Provider name
  • Specific service denied
  • Date of service
  • Denied amount
  • Member responsibility amount
  • Information regarding the providers' appeal rights with Health Net. Include plan name, address and telephone number for appeals.

The Centers for Medicare & Medicaid Services (CMS)-approved Integrated Denial Notice - Notice of Denial of Payment (IDN-NDP) letters must be sent to members when the claim denial results in any member financial liability. The IDN-NDP letter includes the denial notice page, accompanying member appeals language and Notice of Non-Discrimination and mulit-language insert.

For both the denial notice and appeals page, it is not permissible to omit any standardized language, nor alter the template, including font size, without CMS approval. Minor changes to the denial notice page that do not affect the intent of the document may be allowed upon approval from the Medicare Compliance Department.

Delegated participating providers and capitated hospitals may not send denial notices to capitated members if they are not financially liable for the services.

Denial letters to members must not indicate that Health Net or another group is responsible for the claim.

Information required in the space reserved for the explanation of a denial must specify the reasons for the denial, as required under 42 CFR 422.568 (e)(2). For Medicare Advantage providers, the CMS-approved Industry Collaboration Effort (ICE) standardized Single Service Claim Denial Letter and Multiple Services Claim Denial Letter are located under Approved ICE Documents on the ICE website at www.iceforhealth.org/library.asp . Additional information is available on the CMS website at www.cms.gov or from the ICE website at www.iceforhealth.org .

Compliance with Claim Denial Letter Requirements

Health Net conducts ongoing review of delegated participating provider compliance with Medicare and Cal MediConnect claim denial letter requirements.

Last Updated: 10/30/2019