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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
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AcariaHealth
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Byram Healthcare Centers, Inc.
California Department of Health Care Services Subacute Contracting Unit
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Connect Hearing Inc
Coram
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Immunizations
Initial Health Appointment
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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
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Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
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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
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Grievances
Peer-to-Peer Review Requests
Eligibility
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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
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Contractual Financial and Administrative Requirements
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Investigational and Experimental Treatment
OB/GYN Self-Referrals
Out-of-Network Referrals
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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
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Overview
The Plan's Right to Pay Others
When the Plan is the Primary Carrier
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Copayments
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Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
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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
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TurningPoint
Product Descriptions
Primary EPO Plan Overview
Provider Oversight
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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
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Prior Authorization Process
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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
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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
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Division of Juvenile Justice Facilities
Division of Juvenile Justice Program Administrator
Network Providers, LLC (NPLLC)
Prison Health Care Provider Network Provider Services Center
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Byram Healthcare Centers, Inc.
California Department of Health Care Services Subacute Contracting Unit
California Children's Services Program
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Last Updated: 06/26/2023
