Skip to Main Content
HealthNet.com
Enter keyword for site search.
Search
Contrast
On
Off
a
a
a
language
en_us
Provider Login
Line of Business
show Line of Business submenu
Medi-Cal
Medicare Advantage
EPO
HMO
HSP
PPO
Prison Health Care Provider Network
SEARCH
MENU
search
Go!
Privacy Policy
Terms & Conditions
Notice of Privacy Practices
Line of Business
Medi-Cal
Medicare Advantage
EPO
HMO
HSP
PPO
Prison Health Care Provider Network
news
20-092 Prior Authorization Requirements
20-264 Improve Your Access and Availability
20-317 Disease Management Transitioning from Optum to Health Net Integrated Care Management on March 15, 2020
20-408 Use These Guidelines to Improve Trauma-Informed Care for Patients with ACEs
20-465 Changes and Clarifications to Reject Codes 76, AK and C6
20-506 Learn How to Bill ACEs Screening HCPCS Codes G9919 and G9920
20-508 Learn How to Bill ACEs Screening HCPCS Codes G9919 and G9920
20-561 Review New Requirements for Private Duty Nursing for Medi-Cal Members Under Age 21
20-513 Start with Primary Care to Manage High-Risk-Opioid Use
20-963 State of Emergency: Mountain View Fire in Mono County
21-701 The New Provider Portal is Launching Soon!
21-129 Offer 24-Hour Non-Emergency Medical Transportation to Medi-Cal Members Who Need a Ride to Pharmacies and Urgent Care (Dual Risk)
22-060 State of Emergency Due to Winter Storms in Trinity County
22-474 Materials Required in Alternative Formats Based on Member Request
22-726 Monkeypox: Learn About Symptoms, Where to Test and How to Treat
23-346m Bill Correctly to Get Paid for Primary Diagnosis and Interim Claims Submitted
Contacts
AcariaHealth
Access2Care
Access to Interpreter Services
AIDS Waiver Program
Alcohol and Drug Treatment Services
American Specialty Health Plans
Animas Diabetes Care LLC
Apria Healthcare Inc
ATG Rehab Specialists Inc
Behavioral Health Provider Services
Byram Healthcare Centers, Inc.
California Department of Health Care Services Subacute Contracting Unit
California Children's Services Program
California Children's Services Paneling Inquiries
California Department of Social Services State Fair Hearing
CalViva Health Medi-Cal Member Services Department
CalViva Health Medi-Cal Provider Services Center
CalViva Health Nurse Advice Line
Cancer Information Services
Case Management Department
Centers for Medicare & Medicaid Services
Centralized Transplant Unit
Child Health And Disability Prevention Program
Children's Medical Services
Communicable Disease Reporting
Community-Based Adult Services Centers
Community-Based Adult Services Face-To-Face Request Line
Community Health Plan of Imperial Valley Member Services Department
Community Health Plan of Imperial Valley Provider Services Center
Community Health Plan of Imperial Valley Nurse Advice Line
Comprehensive Perinatal Services Program
Connect Hearing Inc
Coram
Custom Rehab Network
County Mental Health Plan
Delta Dental
Dental Benefit Providers
Denti-Cal
Department Of Health Care Services
Department of Insurance
Department Of Managed Health Care
Department Of Social Services (DSS)
Electronic Claims Clearinghouse Information
Envolve Vision
EviCore Healthcare
EyeMed Vision Care
Financial Oversight Department
FitOn Health
Health Care Options (HCO)
Health Net Care Management Department
Health Net CHDP PM160 INF Forms
Health Net Claims Submission
Health Net Continuity and Coordination of Care Department
Health Net Credentialing Department
Health Net Decision Power Referral Fax
Health Net Delegation Oversight Department
Health Net EDI Claims Department
Health Net Elect Claims
Health Net Encounter Department
Health Net Enrollment Services Department
Health Net Facility Site Review Compliance Department
Health Net Fraud Hotline
Health Net Health Education Department
Health Net Health Equity Department
Health Net Hospital Notification Unit
Health Net Long-Term Care Intake Line
Health Net Mail Order Prescription Drug Program
Health Net Marketing Department
Health Net Medi-Cal Claims
Health Net Medi-Cal Facility Site Review Compliance Department
Health Net Medi-Cal Health Services Department
Health Net Medi-Cal Member Appeals And Grievances Department
Health Net Medi-Cal Member Services Department
Health Net Medi-Cal Provider Appeals And Grievances
Health Net Medi-Cal Provider Services Center
Health Net Medicare Advantage Claims Department
Health Net Medicare Advantage Provider Disputes
Health Net Medicare Appeals and Grievances Department
Health Net Medicare Programs Provider Services Department
Health Net Member Appeals and Grievances Department
Health Net Member Services Department
Health Net Provider Communications Department
Health Net Nurse Advice Line
Health Net Overpayment Recovery Department
Health Net PPO Claims Submission
Health Net Prior Authorization Department
Health Net Program Accreditation Department
Health Net Provider Services Center
Health Net Quality Improvement Department
Health Net's Regional Medical Directors
Health Net Third-Party Liability Department
Health Net Transfer/Termination Request Unit
Health Net Transplant Care Manager
Health Net Transportation Vendors
Health Net Utilization Management Department
Health Net Wellness and Prevention Department
Hearing Care Solutions
Hearing Healthcare Providers
HNI Corporate Address
Hoveround Inc
In-Home Operations
J&B Medical Supply Company Inc
Kick It California
LabCorp
Linkia LLC
Livante (California Quality Improvement Organization (QIO)
Los Angeles Department Of Public Social Services
Managed Care Ombudsman
March Vision Care
Matria Health Care Inc
Medical Board Of California
Medi-Cal Provider Contested Claims
Medi-Cal Rx CSC
Medicare Appeals Council
Member Rights Information
MiniMed Distribution Corp Inc
Modivcare
Molina Behavioral Health Services
Molina Claims Department
Molina Credentialing And Facility Site Review Department
Molina Encounter Department
Molina Healthcare Education Department
Molina Healthcare Provider Resolution Department
Molina Interactive Voice Response
Molina Member Services
Molina Nurse Advice Line
Molina Pharmacy Department
Molina PM160 INF Forms
Molina Provider Services Department
Molina Quality Improvement Department
Molina Utilization Management Department
Multipurpose Senior Services
National Imaging Associates Inc
National Seating And Mobility
Nurse Advice Line
Pharmacy Services
Provider Disputes and Appeals - Commercial
Provider Network Management Department
Provider Network Management, Access and Availability Team
Provider Relations Department
Public Programs Coordination Department
Pumping Essentials
Quest Diagnostics
Regional Centers
Reinsurance Claims Unit
River City Medical Group
Roche
San Diego County Aging and Independence Services
San Francisco Medi-Cal Field Office
Smiths Medical Inc
Solutran
Sonus
Special Supplemental Nutrition Program For WIC
State Hearing Division
Teladoc Health
Transplant Team
Transitional Care Services
Tuberculosis Control Program
TurningPoint Healthcare Solutions, LLC
VRI
Wellcare by Health Net Medicare Member Services Department
Terms Glossary
AIDS
Appeal
Certificate of Insurance (COI)
Clean Claim
Clinical Trials
Complaint
Emergency
Evidence of Coverage (EOC)
Facility Site Review
Grievance
Hospice Services
Inquiry
Investigational Services
Medical Necessity
Medical Waste Management Materials
Medical Information
Member Handbook
Not Medically Necessary
Offshore
Opt Out Provider
Participating Provider
Primary Care Physician (PCP)
Psychiatric Emergency Medical Condition
Residential Treatment
Telehealth
Schedule of Benefits or Summary of Benefits (SOB)
Serious Illness
Subcontractor
Unclean Claim
blueprint
calaim
provider-manual
public-programs
child-health-disability-prevention-program
Mental Health
utilization-management
care-management
Hospital and Inpatient Facility Discharge Planning
Notification of Hospital Admissions
eligibility
steps-determine-eligibility
benefits
alcohol-drug-abuse
id-cards
Member ID Card
quality-improvement
Facility Site Review
health-education-program-protocols-
quality-improvement-program
prescription-drug-program
Forms and References
materials
Contacts
Quality Management Program and Resources
Medi-Cal
COVID-19 Provider Alerts
CalAIM
Community Supports
Enhanced Care Management (ECM)
Provider Manual
Adverse Childhood Experiences (ACEs)
Benefits
Access to Sensitive Services
AIDS
Alcohol and Drug Abuse
Acupuncture
Ambulance
Autism Spectrum Disorders
Behavioral Health
Chiropractic
Clinical Trials
Cognitive Health Assessment
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Doula Services
Durable Medical Equipment
Dyadic Services Medi-Cal
Enteral Nutrition
Family Planning
Hearing
HIV Testing and Counseling
Home Health Care
Hospice Care
Immunizations
Incontinence
Initial Health Appointment
Injectables
Long-Term Care
Maternity
Nurse Midwife
Obesity
Podiatry
Preventive Services
Primary Care
Principal Exclusions and Limitations
Second Opinion by a Physician
Street Medicine Services
Subacute Care Facilities
Support for Disabled Members
Transgender Services
Transplants
Transportation
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Tracers
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Emergency Claims Processing
Fee-For-Service Billing and Submission
Professional Claim Editing
Refunds
Reimbursement
Claims Coding Policies
Miscellaneous Coding Policies
Add-On Codes
Allergy Services with Evaluation and Management Services
Assistant Surgeons (State Health Programs)
Basic Coding Guidelines
Bilateral Procedures
Bundled Services and Supplies (State Health Programs)
Co-Surgeons (State Health Programs)
Global Surgery
Incident to Services
Modifier -59
Professional Claim Editing
Provider-Preventable Conditions
Compliance and Regulations
Mandatory Data Sharing Agreement
Provider Marketing Guidelines
Provider Offshore Subcontracting Attestation
Communicable Diseases Reporting
DMHC-Required Statement on Written Correspondence
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Drug Utilization Review Requirements
Consent
Consent for Breast and Prostate Center Treatment
Consent for Treatment
Human Sterilization and Informed Consent
Coordination of Benefits
Overview
Copayments
Verifying and Clearing Share-of-Cost
Credentialing
Application Process
Site Evaluations
Denial Notification
Denial Letter Translation Assistance for Members
Notification Delays
Required Elements for Member Notification Letters
Required Elements for Provider Notification Letters
Requirements for Notification of Utilization Management Decisions
Disenrollment
Appeals, Grievances and Disputes
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Peer-to-Peer Review Requests
Eligibility
Eligibility Verification
Children
Share of Cost for Medi-Cal Members
Eligibility Reports
Eligibility Reports
Molina Healthcare Eligibility Reports
Emergency Services
Coverage Explanation
Additional Monitoring Responsibilities
Hospital Request for Authorization to Provide Post-Stabilization Services
Out-of-Area Emergency or Urgently Needed Care
PPG Responsibilities
Procedures to Report System & Protocol Failures
Encounters
Overview
Dual-Risk Contracts Encounter Data Submission
Error Notification
Noncompliance with Encounter Data Submission
Professional and Institutional Capitated Encounter Submission Requirements
Enrollment
Member Enrollment
Use of Social Security Numbers
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medi-Cal Medical Records Reviews
Medical Record Documentation
Member Rights and Responsibilities
Overview
Advance Directives
Member Confidentiality
PCP Selection and Assignment
Prescription Drug Program
Prior Authorizations
Requesting Prior Authorization or Coordinating a PCP Referral
Advanced and Cardiac Imaging
How to Secure Prior Authorization on the Provider Portal
Notification of Inpatient Admissions
Prior Authorization
Request for Prior Authorization Form
Services Not Requiring Prior Authorization
Product Descriptions
Medi-Cal Managed Care
Provider Oversight
Overview
Appeals and Grievances
Calendar of Required PPG Submissions
Conditions of PCP Panel Closures by Health Net
Corrective Action Plan
Credible Allegations of Fraud
Fraud, Waste and Abuse
Provider Enrollment Requirement Through DHCS
Monitoring Provider Exclusions
Subdelegated Functions
Contractual Financial and Administrative Requirements
Delegated Medical Management
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Public Programs
AIDS Waiver Program
Alcohol and Drug Screening, Assessment, Brief Interventions and Referral to Treatment
California Children's Services
Child Health and Disability Prevention (CHDP) Program
DDS-Administered Home and Community Based Services (HCBS) Waiver
Early Start Program
EPSDT Services
Hansen's Disease
Home and Community Based Waiver
Local Education Agency Services
Long-Term Services and Supports
Mental Health
Refugee Health Programs
Regional Center Coordination
Sexually Transmitted Infections (STIs)
Tuberculosis Detection and Treatment
WIC
Quality Improvement
Disease Management Programs
Facility Site Review
Health Management Programs
Language Assistance Program and Cultural Competency
Medi-Cal Quality Improvement Programs
Health Education
Quality Improvement Program
Referrals
Investigational and Experimental Treatment
Molina Healthcare Lab Referrals
Molina Healthcare Service Request Form
Primary Care Services
Receipt of Specialist's Report
Referral Tracking
Referrals for Specialty Consultation
Referrals to Specialists
Services Not Requiring Referral or Prior Authorization
Standing Referrals to a Specialist
Third-Party Liability
Overview
Provider Responsibilities
Urgent Care
Utilization Management
Overview
Advice Nurse Telephone Triage and Screening Program
Affiliated Health Plan Delegated Utilization Management - Reporting
Care Continuation
Care Management
Clinical Criteria for Medical Management Decision Making
Clinical Criteria for Utilization and Care Management Decisions
Concurrent and Retrospective Review
Continuity of Care
Discharge Notification
Hospital and Inpatient Facility Discharge Planning
Notification of Hospital Admissions
Out-of-Area Service
Prescription Utilization Review
Prior Authorization
Separation of Medical Decisions and Financial Concerns
Utilization Management Program Components
Behavioral Health Provider Operations Manual
Prior Authorization Requirements
Participating Physician Group (PPG) Performance Scorecard
Payment Policies
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Provider Pulse Newsletter
Contacts
Glossary
Quality Management Program and Resources
Medicare Advantage
COVID-19 Provider Alerts
D-SNP
Provider Manual
Benefits
Overview
Acupuncture
AIDS
Alcohol and Drug Abuse
Allergy Treatment
Ambulance
Bariatric Surgery
Behavioral Health
Blood
Chemotherapy
Chiropractic
Clinical Trials
Complementary Supplemental Benefits
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Durable Medical Equipment
Enteral Nutrition
Family Planning
General Benefit Exclusions and Limitations
Hearing
HIV Testing and Counseling
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Initial Health Appointment
Injectables
Maternity
Medical Social Services
Nurse Midwife
Obesity
Outpatient Services
Physicians Visit
Podiatry
Post Stabilization
Preventive Services
Prosthesis
Rehabilitation Therapy
Respite Care
Routine Physical Exam
Second Opinion by a Physician
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Transportation
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility and Capitation
Eligibility Guarantee
Fee-For-Service Billing and Submission
Institutionalized Members
Medicare Risk Adjustment Report
Payment for Service of Non-Participating Providers
Professional Claim Editing
Professional Stop Loss
Provider Participation Agreement
Refunds
Reimbursement
Reinsurance
Schedule of Benefits and Summary of Benefits
Shared Risk
When Medicare is a Secondary Payer
Claims Coding Policies
Code Editing
Compliance and Regulations
Mandatory Data Sharing Agreement
Medicare Communications and Marketing Guidelines
Provider Offshore Subcontracting Attestation
Approval of Medicare Communications and Marketing Guidelines
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
COB Payment Calculations
Determination of Primary Insurer
Medicare Plus (Plan J or HJA)
Recovery of Excessive Payments
The Plan's Right to Pay Others
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Collection of Copayments for Referrals
Collection of Medicare Copayments
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
Claims Denial Requirements
Denial of Investigational or Experimental Treatment for a Terminal Illness
Service Denial Templates
Integrated Denial Notification - Notice of Denial Medical Coverage Template Information
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notification Delays
Requirements for Notification of Utilization Management Decisions
Disenrollment
Appeals, Grievances and Disputes
Expedited Reviews
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Peer-to-Peer Review Requests
Eligibility
COBRA Continuation
Dual-Eligible Medicare Beneficiaries
Steps to Determine Eligibility
Eligibility Reports
Eligibility Reports
Health Net Medicare Advantage Capitation Eligibility Summary Reports by Group and Provider
Health Net Medicare Advantage Reconciliation Report
Emergency Services
Coverage Explanation
Additional Monitoring Responsibilities
Instructions to Members Regarding Authorization
Out-of-Area Emergency or Urgently Needed Care
PPG Responsibilities
Encounters
Overview
Dual-Risk Contracts Encounter Data Submission
Error Notification
Lien Recoveries
Noncompliance with Encounter Data Submission
Professional and Institutional Capitated Encounter Submission Requirements
Enrollment
Annual Election and Enrollment Periods
Member Enrollment
Part D Enrollment
Subscriber and Member Identification Numbers
Use of Social Security Numbers
Administration of New Member Procedure
Conditions for Transfer Between PPGs
Member Terminations
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Confidentiality of Medical Records
Medical Record Documentation
Medical Record Forms and Aids
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Medicare Advantage Part B
Accessing Part D Prescription Medications
Compounded Medications
Coverage Explanation
Generic Medications
Medication Therapy Management Program
Participating Pharmacy
TransactRx
Prior Authorizations
Overview
Authorization for Admission to Hospital or SNF
Diagnostic Procedures
How to Secure Prior Authorization on the Provider Portal
PPGs' Responsibilities for Authorization
Prior Authorization Process for Direct Network Practitioners
Product Descriptions
Medicare Select Plan Description
Medicare Plans
Optional Supplemental Benefits Package
Provider Oversight
Overview
Calendar of Required PPG Submissions
Corrective Action Plan
Fraud, Waste and Abuse
Member Appeals and Grievances
Monitoring Provider Exclusions
Special Needs Plan Model of Care
Subdelegated Functions
Contractual Financial and Administrative Requirements
Delegated Medical Management
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Disease Management Programs
Health Education Program
Health Management Programs
Language Assistance Program and Cultural Competency
Quality Improvement Program
Referrals
Overview
Direct Network Referral Process
Investigational and Experimental Treatment
OB/GYN Self-Referrals
Out-of-Network Referrals
Post-Stabilization Care
Role of the Primary Care Physician
Self-Referral Benefits
Third-Party Liability
Coverage Explanation
Urgent Care
Utilization Management
Overview
Affirmative Statement About Incentives
Availability of Criteria
Care Management
Clinical Criteria for Medical Management Decision Making
Continuity of Care
Coverage Determination
Health Risk Assessment
Medical Data Management Reporting
Medical Data Management System
Medicare Certified Facilities
Non-Delegated Medical Management
Notification of Hospital Admissions
Notification of Hospital Discharge Appeal Rights
Out-of-Area Services
Separation of Medical Decisions and Financial Concerns
Termination of Provider Services
Utilization Management Goal
Utilization Management Program Components
Behavioral Health Provider Operations Manual
Prior Authorization Requirements
Participating Physician Group (PPG) Performance Scorecard
Payment Policies
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Provider Pulse Newsletter
Contacts
Glossary
Quality Management Program and Resources
EPO
COVID-19 Provider Alerts
Provider Manual
Adverse Childhood Experiences (ACEs)
Benefits
Acupuncture
Alcohol and Drug Abuse
Allergy Treatment
Ambulance
Autism Spectrum Disorders
Bariatric Surgery
Behavioral Health
Blood
Chemotherapy
Chiropractic
Clinical Trials
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Durable Medical Equipment
Essential Health Benefits
Family Planning
General Benefit Exclusions and Limitations
Genetic Testing
Hearing
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Injectables
Maternity
Medical Social Services
Nuclear Medicine
Obesity
Outpatient Services
Periodic Health Evaluations
Physicians Visit
Preventive Services
Prosthesis
Rehabilitation Therapy
Routine Physical Exam
Second Opinion by a Physician
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Compliance for Transplant Performance Centers Standardized Process
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility and Capitation
Eligibility Guarantee
Fee-For-Service Billing and Submission
Professional Claim Editing
Refunds
Reimbursement
Salud con Health Net
Schedule of Benefits and Summary of Benefits
Timely Filing Criteria
When Medicare is a Secondary Payer
Claims Coding Policies
Code Editing
Compliance and Regulations
Mandatory Data Sharing Agreement
Provider Offshore Subcontracting Attestation
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
The Plan's Right to Pay Others
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Calculation of Coinsurance
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
Service Denial Templates
Member Denial Letter Templates
Required Elements for Provider Notification Letters
Requirements for Notification of Utilization Management Decisions
Appeals, Grievances and Disputes
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Eligibility
Extension of Benefits
Provider Responsibility for Verifying Eligibility for On-Exchange IFP Members in Delinquent Premium Grace Period
Steps to Determine Eligibility
Emergency Services
Overview
Additional Monitoring Responsibilities
Instructions to Members Regarding Authorization
Out-of-Area Emergency or Urgently Needed Care
Encounters
Overview
Lien Recoveries
Enrollment
Subscriber and Member Identification Numbers
Use of Social Security Numbers
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medical Record Documentation
Medical Record Forms and Aids
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Compounded Medications
Diabetic Supplies
Exclusions and Limitations
Generic Medications
Off-Label Medication Use
Participating Pharmacy
Physician Self-Treatment
Prescription Mail-Order Program
Prior Authorization Process
Quantity of Medication to Be Prescribed
Recommended Drug List and Cal MediConnect Formulary
Prior Authorizations
How to Secure Prior Authorization on the Provider Portal
NIA - Prior Authorization
Prior Authorization Process for Direct Network Practitioners
TurningPoint
Product Descriptions
Primary EPO Plan Overview
Provider Oversight
Fraud, Waste and Abuse
Monitoring Provider Exclusions
Contractual Financial and Administrative Requirements
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Disease Management Programs
Health Education Program
Language Assistance Program and Cultural Competency
Quality Improvement Program
Referrals
Direct Network Referral Process
Investigational and Experimental Treatment
OB/GYN Self-Referrals
Third-Party Liability
Coverage Explanation
Utilization Management
Overview
Care Management
Clinical Criteria for Medical Management Decision Making
Continuity of Care
Economic Profiling
Hospital and Inpatient Facility Discharge Planning
Medical Data Management System
Non-Delegated Medical Management
Notification of Hospital Admissions
Out-of-Area Services
Separation of Medical Decisions and Financial Concerns
Utilization Management Goal
Utilization Management Program Components
Behavioral Health Provider Operations Manual
Prior Authorization Requirements
Participating Physician Group (PPG) Performance Scorecard
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Contacts
Glossary
Quality Management Program and Resources
HMO
COVID-19 Provider Alerts
Provider Manual
Adverse Childhood Experiences (ACEs)
Benefits
Acupuncture
AIDS
Alcohol and Drug Abuse
Allergy Treatment
Ambulance
Autism Spectrum Disorders
Bariatric Surgery
Behavioral Health
Blood
Chemotherapy
Chiropractic
Clinical Trials
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Durable Medical Equipment
Essential Health Benefits
Family Planning
General Benefit Exclusions and Limitations
Genetic Testing
Hearing
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Incarcerated Members
Initial Health Appointment
Injectables
Maternity
Medical Social Services
Nuclear Medicine
Nurse Midwife
Obesity
Outpatient Services
Periodic Health Evaluations
Physicians Visit
Preventive Services
Prosthesis
Rehabilitation Therapy
Routine Physical Exam
Second Opinion by a Physician
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility and Capitation
Eligibility Guarantee
Emergency Claims Processing
Fee-For-Service Billing and Submission
Insured Services
Premium Payment Grace Period for Beneficiary Qualifying for APTC
Professional Claim Editing
Professional Stop Loss
Refunds
Reimbursement
Reinsurance
Schedule of Benefits and Summary of Benefits
Shared Risk
Timely Filing Criteria
When Medicare is a Secondary Payer
Claims Coding Policies
Code Editing
Compliance and Regulations
Mandatory Data Sharing Agreement
Provider Offshore Subcontracting Attestation
Communicable Diseases Reporting
DMHC-Required Statement on Written Correspondence
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
COB Payment Calculations
Disagreements with Other Insurers
Duplicate Plan Coverage
Medicare Plus (Plan J or HJA)
Order of Benefit Determination
Recovery of Excessive Payments
Services Instead of Cash Payments
The Plan's Right to Pay Others
TRICARE/CHAMPVA
Veterans' Administration
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Calculation of Coinsurance
Collection of Copayments
Collection of Copayments for Referrals
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
Claims Denial Letter Requirements
Denial of Investigational or Experimental Treatment for a Terminal Illness
Service Denial Templates
Member Denial Letter Templates
Notification Delays
Required Elements for Provider Notification Letters
Requirements for Notification of Utilization Management Decisions
Appeals, Grievances and Disputes
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Peer-to-Peer Review Requests
Eligibility
COBRA Continuation
COBRA Coverage Terminates While Member Is Hospitalized or In SNF
Extension of Benefits
Provider Responsibility for Verifying Eligibility for On-Exchange IFP Members in Delinquent Premium Grace Period
Steps to Determine Eligibility
Suspension of Coverage Letter
Eligibility Reports
Active Analysis Report
Emergency Services
Overview
Additional Monitoring Responsibilities
Instructions to Members Regarding Authorization
Hospital Request for Authorization to Provide Post-Stabilization Services
Out-of-Area Emergency or Urgently Needed Care
PPG Responsibilities
Encounters
Overview
Dual-Risk Contracts Encounter Data Submission
Error Notification
Lien Recoveries
Noncompliance with Encounter Data Submission
Professional and Institutional Capitated Encounter Submission Requirements
Enrollment
Dependent Documentation Provided to Non-Subscriber
Subscriber and Member Identification Numbers
Use of Social Security Numbers
Administration of New Member Procedure
Conditions for Transfer Between PPGs
Late Enrollment Rules Waived
Member Terminations
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medical Record Documentation
Medical Record Forms and Aids
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Compounded Medications
Diabetic Supplies
Exclusions and Limitations
Generic Medications
Off-Label Medication Use
Participating Pharmacy
Physician Self-Treatment
Prescription Mail-Order Program
Prior Authorization Process
Quantity of Medication to Be Prescribed
Recommended Drug List and Cal MediConnect Formulary
Prior Authorizations
Overview
Authorization for Admission to Hospital or SNF
Ambetter HMO PPGs
Hospice Authorization
How to Secure Prior Authorization on the Provider Portal
NIA - Prior Authorization
PPGs' Responsibilities for Authorization
Prior Authorization Process for Direct Network Practitioners
Product Descriptions
Point of Service (POS) Product
Ambetter HMO
Elect Open Access Two Tier Plan
Elect Two Tier Plan
ExcelCare
HMO
HMO SmartCare
Leased PPO Benefit Program
Select Three Tier Plan
Select Two Tier Plan
Provider Oversight
Overview
Calendar of Required PPG Submissions
Corrective Action Plan
Fraud, Waste and Abuse
Member Appeals and Grievances
Monitoring Provider Exclusions
Monitoring Provider Sanctions for the Federal Employees Health Benefit Program
Subdelegated Functions
Contractual Financial and Administrative Requirements
Delegated Medical Management
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Disease Management Programs
Health Education Program
Health Management Programs
Language Assistance Program and Cultural Competency
Quality Improvement Program
Referrals
Direct Network Referral Process
Investigational and Experimental Treatment
OB/GYN Self-Referrals
Out-of-Network Referrals
Post-Stabilization Care
Referrals for Specialty Consultation
Standing Referrals to a Specialist
Third-Party Liability
Coverage Explanation
Urgent Care
Utilization Management
Overview
Care Management
Clinical Criteria for Medical Management Decision Making
Concurrent and Retrospective Review
Continuity of Care
Economic Profiling
Hospital and Inpatient Facility Discharge Planning
Medical Data Management System
Non-Delegated Medical Management
Notification of Hospital Admissions
Out-of-Area Services
Separation of Medical Decisions and Financial Concerns
Utilization Management Goal
Utilization Management Program Components
Behavioral Health Provider Operations Manual
Prior Authorization Requirements
Participating Physician Group (PPG) Performance Scorecard
Payment Policies
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Provider Pulse Newsletter
Contacts
Glossary
Quality Management Program and Resources
HSP
COVID-19 Provider Alerts
Provider Manual
Adverse Childhood Experiences (ACEs)
Benefits
Acupuncture
Alcohol and Drug Abuse
Allergy Treatment
Ambulance
Autism Spectrum Disorders
Bariatric Surgery
Behavioral Health
Blood
Chemotherapy
Chiropractic
Dental Services
Dialysis
Durable Medical Equipment
Essential Health Benefits
Family Planning
General Benefit Exclusions and Limitations
Genetic Testing
Hearing
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Injectables
Maternity
Medical Social Services
Nuclear Medicine
Nurse Midwife
Outpatient Services
Periodic Health Evaluation
Preventive Services
Prosthesis
Rehabilitation Therapy
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility Guarantee
Emergency Claims Processing
Fee-For-Service Billing and Submission
Premium Payment Grace Period for Beneficiary Qualifying for APTC
Professional Claim Editing
Refunds
Reimbursement
Reinsurance
Schedule of Benefits and Summary of Benefits
Timely Filing Criteria
When Medicare is a Secondary Payer
Claims Coding Policies
Code Editing
Compliance and Regulations
Mandatory Data Sharing Agreement
Provider Offshore Subcontracting Attestation
Communicable Diseases Reporting
DMHC-Required Statement on Written Correspondence
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
COB Payment Calculations
Disagreements with Other Insurers
Duplicate Plan Coverage
Medicare Plus (Plan J or HJA)
Order of Benefit Determination
Recovery of Excessive Payments
Services Instead of Cash Payments
The Plan's Right to Pay Others
TRICARE/CHAMPVA
Veterans' Administration
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Calculation of Coinsurance
Collection of Copayments
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
Denial of Investigational or Experimental Treatment for a Terminal Illness
Notification Delays
Required Elements for Provider Notification Letters
Requirements for Notification of Utilization Management Decisions
Appeals, Grievances and Disputes
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Eligibility
Extension of Benefits
Provider Responsibility for Verifying Eligibility for On-Exchange IFP Members in Delinquent Premium Grace Period
Steps to Determine Eligibility
Emergency Services
Overview
Enrollment
Subscriber and Member Identification Numbers
Use of Social Security Numbers
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medical Record Documentation
Medical Record Forms and Aids
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Compounded Medications
Diabetic Supplies
Exclusions and Limitations
Generic Medications
Off-Label Medication Use
Participating Pharmacy
Physician Self-Treatment
Prescription Mail-Order Program
Prior Authorization Process
Quantity of Medication to Be Prescribed
Recommended Drug List and Cal MediConnect Formulary
Prior Authorizations
How to Secure Prior Authorization on the Provider Portal
NIA - Prior Authorization
Prior Authorization Process for Direct Network Practitioners
Product Descriptions
PureCare HSP (Large Group)
Provider Oversight
Fraud, Waste and Abuse
Monitoring Provider Exclusions
Contractual Financial and Administrative Requirements
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Language Assistance Program and Cultural Competency
Quality Improvement Program
Referrals
Investigational and Experimental Treatment
Out-of-Network Providers
PureCare (Large Group) HSP Referral Process
Third-Party Liability
Coverage Explanation
Utilization Management
Care Management
Continuity of Care
Economic Profiling
Hospital and Inpatient Facility Discharge Planning
Medical Data Management System
Medical Management
Notification of Hospital Admissions
Separation of Medical Decisions and Financial Concerns
Utilization Management Goal
Behavioral Health Provider Operations Manual
Prior Authorization Requirements
Participating Physician Group (PPG) Performance Scorecard
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Contacts
Glossary
Quality Management Program and Resources
PPO
COVID-19 Provider Alerts
Provider Manual
Adverse Childhood Experiences (ACEs)
Benefits
Acupuncture
Alcohol and Drug Abuse
Allergy Treatment
Ambulance
Autism Spectrum Disorders
Bariatric Surgery
Behavioral Health
Blood
Clinical Trials
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Durable Medical Equipment
Essential Health Benefits
Family Planning
General Benefit Exclusions and Limitations
Genetic Testing
Hearing
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Incarcerated Members
Maternity
Medical Social Services
Nuclear Medicine
Nurse Midwife
Obesity
Outpatient Services
Periodic Health Evaluations
Preventive Services
Prosthesis
Rehabilitation Therapy
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility Guarantee
Fee-For-Service Billing and Submission
PPO Billing
Premium Payment Grace Period for Beneficiary Qualifying for APTC
Professional Claim Editing
Refunds
Reimbursement
Salud con Health Net
Schedule of Benefits and Summary of Benefits
Timely Filing Criteria
When Medicare is a Secondary Payer
Claims Coding Policies
Code Editing
Compliance and Regulations
Mandatory Data Sharing Agreement
Provider Offshore Subcontracting Attestation
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
COB Payment Calculations
Disagreements with Other Insurers
The Plan's Right to Pay Others
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Calculation of Coinsurance
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
State Requirement for Providing Behavioral Health Services
Denial Notification
Service Denial Templates
Member Denial Letter Templates
Required Elements for Member Notification Letters
Required Elements for Provider Notification Letters
Requirements for Notification of Utilization Management Decisions
Appeals, Grievances and Disputes
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Peer-to-Peer Review Requests
Eligibility
COBRA Continuation
Extension of Benefits
Provider Responsibility for Verifying Eligibility for On-Exchange IFP Members in Delinquent Premium Grace Period
Steps to Determine Eligibility
Emergency Services
Overview
Encounters
Lien Recoveries
Enrollment
Dependent Documentation Provided to Non-Subscriber
Subscriber and Member Identification Numbers
Use of Social Security Numbers
Late Enrollment Rules Waived
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medical Record Documentation
Medical Record Forms and Aids
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Compounded Medications
Coverage Explanation
Diabetic Supplies
Exclusions and Limitations
Generic Medications
Off-Label Medication Use
Participating Pharmacy
Physician Self-Treatment
Prescription Mail-Order Program
Prior Authorization Process
Quantity of Medication to Be Prescribed
Recommended Drug List and Cal MediConnect Formulary
Prior Authorizations
Fax Requests
How to Secure Prior Authorization on the Provider Portal
NIA - Prior Authorization
PPO Services Requiring Prior Authorization
Prior Authorization Process
TurningPoint
Product Descriptions
Point of Service (POS) Product
Elect Open Access Two Tier Plan
Elect Two Tier Plan
Ambetter PPO
Health Savings Accounts (HSAs)
Leased PPO Benefit Program
PPO Product
Select Three Tier Plan
Select Two Tier Plan
Provider Oversight
Fraud, Waste and Abuse
Monitoring Provider Exclusions
Contractual Financial and Administrative Requirements
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Disease Management Programs
Health Education Program
Health Management Programs
Language Assistance Program and Cultural Competency
Quality Improvement Program
Referrals
Overview
Investigational and Experimental Treatment
Lab and X-Ray Referrals
Third-Party Liability
Coverage Explanation
Utilization Management
Overview
Care Management
Clinical Criteria for Medical Management Decision Making
Continuity of Care
Economic Profiling
Hospital and Inpatient Facility Discharge Planning
Medical Data Management System
Non-Delegated Medical Management
Notification of Hospital Admissions
Utilization Management Goal
Behavioral Health Provider Operations Manual
Prior Authorization Requirements
Participating Physician Group (PPG) Performance Scorecard
Payment Policies
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Provider Pulse Newsletter
Contacts
Glossary
Quality Management Program and Resources
Prison Health Care Provider Network
COVID-19 Provider Alerts
Provider Manual
California Correctional Health Care Services Formulary
Claims and Provider Reimbursement
Clinical Quality Management
Compliance and Regulations
Credentialing
Dispute Resolution and Appeals
Emergency Services
Hospital Services
Medical Parolees
Medical Records
Off-Site Medical Imaging Facilities
Off-site Radiology Services
On-Site and Mobile Medical Imaging
On-Site Specialty Care Providers
Pathology Services
Prior Authorization
Provider Oversight
Provider Oversight | Access to Care and Availability Standards
Provider Oversight | Psychiatric Provider Responsibilities
Reentry Programs
Safety and Security Procedures
Service Delivery Obligations
Telemedicine
Updates and Letters
Forms and References
Education, Training and Other Materials
Contacts
Availity, LLC
California Correctional Health Care Services
California Correctional Health Care Services - Appeals
California Correctional Health Care Services - Disputes
California Correctional Health Care Services Help Desk
California Correctional Health Care Services Imaging Records Center
California Correctional Health Care Services (CCHCS) Reentry Programs (REPS) Contacts
California Correctional Health Care Services Office of Telemedicine
California Correctional Health Care Services Provider Appeals and Refunds
California Department of Corrections and Rehabilitation
California Department of Corrections and Rehabilitation - Health Care On-Site Contractor's Orientation Handbook
CorrectCare Integrated Health
Credentialing Department
Division of Juvenile Justice
Division of Juvenile Justice Facilities
Division of Juvenile Justice Program Administrator
Network Providers, LLC (NPLLC)
Prison Health Care Provider Network Provider Services Center
language
en_us
HealthNet.com
Contacts
AcariaHealth
Access2Care
Access to Interpreter Services
AIDS Waiver Program
Alcohol and Drug Treatment Services
American Specialty Health Plans
Animas Diabetes Care LLC
Apria Healthcare Inc
ATG Rehab Specialists Inc
Behavioral Health Provider Services
Byram Healthcare Centers, Inc.
California Department of Health Care Services Subacute Contracting Unit
California Children's Services Program
California Children's Services Paneling Inquiries
California Department of Social Services State Fair Hearing
CalViva Health Medi-Cal Member Services Department
CalViva Health Medi-Cal Provider Services Center
CalViva Health Nurse Advice Line
Cancer Information Services
Case Management Department
Centers for Medicare & Medicaid Services
Centralized Transplant Unit
Child Health And Disability Prevention Program
Children's Medical Services
Communicable Disease Reporting
Community-Based Adult Services Centers
Community-Based Adult Services Face-To-Face Request Line
Community Health Plan of Imperial Valley Member Services Department
Community Health Plan of Imperial Valley Provider Services Center
Community Health Plan of Imperial Valley Nurse Advice Line
Comprehensive Perinatal Services Program
Connect Hearing Inc
Coram
Custom Rehab Network
County Mental Health Plan
Delta Dental
Dental Benefit Providers
Denti-Cal
Department Of Health Care Services
Department of Insurance
Department Of Managed Health Care
Department Of Social Services (DSS)
Electronic Claims Clearinghouse Information
Envolve Vision
EviCore Healthcare
EyeMed Vision Care
Financial Oversight Department
FitOn Health
Health Care Options (HCO)
Health Net Care Management Department
Health Net CHDP PM160 INF Forms
Health Net Claims Submission
Health Net Continuity and Coordination of Care Department
Health Net Credentialing Department
Health Net Decision Power Referral Fax
Health Net Delegation Oversight Department
Health Net EDI Claims Department
Health Net Elect Claims
Health Net Encounter Department
Health Net Enrollment Services Department
Health Net Facility Site Review Compliance Department
Health Net Fraud Hotline
Health Net Health Education Department
Health Net Health Equity Department
Health Net Hospital Notification Unit
Health Net Long-Term Care Intake Line
Health Net Mail Order Prescription Drug Program
Health Net Marketing Department
Health Net Medi-Cal Claims
Health Net Medi-Cal Facility Site Review Compliance Department
Health Net Medi-Cal Health Services Department
Health Net Medi-Cal Member Appeals And Grievances Department
Health Net Medi-Cal Member Services Department
Health Net Medi-Cal Provider Appeals And Grievances
Health Net Medi-Cal Provider Services Center
Health Net Medicare Advantage Claims Department
Health Net Medicare Advantage Provider Disputes
Health Net Medicare Appeals and Grievances Department
Health Net Medicare Programs Provider Services Department
Health Net Member Appeals and Grievances Department
Health Net Member Services Department
Health Net Provider Communications Department
Health Net Nurse Advice Line
Health Net Overpayment Recovery Department
Health Net PPO Claims Submission
Health Net Prior Authorization Department
Health Net Program Accreditation Department
Health Net Provider Services Center
Health Net Quality Improvement Department
Health Net's Regional Medical Directors
Health Net Third-Party Liability Department
Health Net Transfer/Termination Request Unit
Health Net Transplant Care Manager
Health Net Transportation Vendors
Health Net Utilization Management Department
Health Net Wellness and Prevention Department
Hearing Care Solutions
Hearing Healthcare Providers
HNI Corporate Address
Hoveround Inc
In-Home Operations
J&B Medical Supply Company Inc
Kick It California
LabCorp
Linkia LLC
Livante (California Quality Improvement Organization (QIO)
Los Angeles Department Of Public Social Services
Managed Care Ombudsman
March Vision Care
Matria Health Care Inc
Medical Board Of California
Medi-Cal Provider Contested Claims
Medi-Cal Rx CSC
Medicare Appeals Council
Member Rights Information
MiniMed Distribution Corp Inc
Modivcare
Molina Behavioral Health Services
Molina Claims Department
Molina Credentialing And Facility Site Review Department
Molina Encounter Department
Molina Healthcare Education Department
Molina Healthcare Provider Resolution Department
Molina Interactive Voice Response
Molina Member Services
Molina Nurse Advice Line
Molina Pharmacy Department
Molina PM160 INF Forms
Molina Provider Services Department
Molina Quality Improvement Department
Molina Utilization Management Department
Multipurpose Senior Services
National Imaging Associates Inc
National Seating And Mobility
Nurse Advice Line
Pharmacy Services
Provider Disputes and Appeals - Commercial
Provider Network Management Department
Provider Network Management, Access and Availability Team
Provider Relations Department
Public Programs Coordination Department
Pumping Essentials
Quest Diagnostics
Regional Centers
Reinsurance Claims Unit
River City Medical Group
Roche
San Diego County Aging and Independence Services
San Francisco Medi-Cal Field Office
Smiths Medical Inc
Solutran
Sonus
Special Supplemental Nutrition Program For WIC
State Hearing Division
Teladoc Health
Transplant Team
Transitional Care Services
Tuberculosis Control Program
TurningPoint Healthcare Solutions, LLC
VRI
Wellcare by Health Net Medicare Member Services Department
Connect Hearing Inc
Back to previous page
888-608-7462
Connect Hearing website
Last Updated: 01/18/2024
