Professional Encounter Submission Requirements

Provider Type

  • Participating Physician Groups (PPG)
  • Ancillary

Providers may submit encounters to Health Net directly or through an authorized electronic data interchange (EDI) vendor or clearinghouse. To initiate or discuss the submission of encounter data files, contact the Capitated Claims/Encounter Department. This department also supports electronic encounter submission via file transfer protocol (FTP).

All professional encounters must be submitted in an electronic format. For additional information about how to submit encounters electronically, refer to 837 5010 Professional and Institutional Standards (PDF) or 837 Professional Companion Guide (PDF).

Capitated providers are contractually required to submit complete and correct data for all professional services performed. Before submitting encounter data, the submitter should contact the Health Net Encounter Department to discuss submission format and data requirements. Health Net currently accepts the ANSI 837 5010 X12 format.

All data should be submitted according to the terms of the Provider Participation Agreement (PPA). If the participating physician group (PPG) does not submit data within this time frame, the PPG is excluded from eligibility for the Health Net Quality of Care Improvement Program (QCIP) (applicable only for HMO and Point of Service (POS) products).