Provider Responsibilities

Requests from Health Net

If the Department of Health Care Services (DHCS) requests information regarding an individual third-party tort liability case, Health Net notifies the provider. The provider must supply Health Net with copies of the requested documents within the time frame included in the notification in order for Health Net to deliver the information to DHCS within 10 to 30 days of the request. Providers should submit the information to the Health Net Third-Party Liability Department.

Notifying Health Net of Requests

Notify Health Net or the participating physician group (PPG) in writing of all potential and confirmed third-party tort liability cases involving a Health Net Medi-Cal or Cal MediConnect member.

Notify Health Net if the provider receives any subpoenas from attorneys, insurers or members for copies of bills. Supply Health Net with copies of the request and copies of documents released as a result of the request, and provide the name, address and telephone number of the requesting party. Mail notifications to the Health Net Third Party Liability Department.

The notifications must include:

• Member name
• Member 14-digit Medi-Cal number
• Member identification (ID) number
• Date of birth
• Contractor name (for example, Health Net)
• Provider name and address
• Dates of service
• Diagnosis code, description of the illness or injury or both
• Procedure code, description of the services rendered or both
• Billed amount
• Amounts paid by other insurance (if any)
• Amount and date paid by Health Net to participating or non-participating provider (if any)
• Date of denial and reasons (if any)

In all third-party tort liability cases, providers must bill Health Net or the PPG as usual, and give all details regarding the injury or illness. Health Net pays usual benefits, and refers the case to DHCS to pursue the recovery.