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Provider Responsibility for Verifying Eligibility for On-Exchange IFP Members in Delinquent Premium Grace Period

Provider Type

  • Physicians
  • Participating Physician Groups (PPG) 
    (does not apply to HSP)
  • Hospitals
  • Ancillary

It is imperative that providers verify benefits, eligibility and cost shares each time a member is scheduled to receive services. Presentation of a member identification (ID) card is not a guarantee of eligibility. Providers must always verify eligibility on the same day services are required.

To verify eligibility for Individual Family Plan (IFP) members, providers can utilize the Health Net provider portal at provider.healthnetcalifornia.com.

PREMIUM GRACE PERIOD FOR MEMBERS RECEIVING FEDERAL ADVANCE PREMIUM TAX CREDITS AND/OR CALIFORNIA PREMIUM SUBSIDIES

Provisions of the Affordable Care Act and California law require that Health Net allow members receiving federal Advance Premium Tax Credits (APTCs) and/or California premium subsidies a three-month grace period to pay premiums before coverage is terminated.

  • Members receiving federal APTCs and/or California premium subsidies will have a federally mandated grace period of three months in which to make payment for their portion of the premium.
    • Premiums are billed and paid at the subscriber level; therefore, the grace period is applied at the subscriber level.
    • All members associated with the subscriber will inherit the enrollment status of the subscriber.
    • When providers are verifying eligibility through the secure provider portal during the first month of nonpayment of premium, the provider will receive a message that the member is active but delinquent due to nonpayment of premium. However, claims may be submitted and Health Net will pay for covered services rendered during the first month of the grace period.
    • During months two and three of the grace period, the member's eligibility status is suspended, and claims will be pended. The EX code on the explanation of payment will state: "LZ - Pend: Non-Payment of Premium."
    • Coverage will remain in force during the grace period.
    • If payment of all premiums due is not received from the member by the end of the three-month grace period, the member's policy will automatically terminate to the last day of the first month of the grace period.
    • The member will be financially responsible for the cost of covered services received during the second and third months of the grace period, as well as any unpaid premium.
    • In no event shall coverage extend beyond the date the member policy terminates.

BILLING FOR COVERED SERVICES TO MEMBERS IN SUSPENDED STATUS DURING MONTHS TWO AND THREE

For members whose eligibility is in a suspended status and seeking services from providers:

  1. Providers may advise the member that providers are not obligated under their Health Net contract to provide services while the member's eligibility is in suspended status. (Status must be verified through the Health Net secure provider portal or by calling Provider Services. Providers should follow their internal policies and procedures regarding this situation.)
  2. Should a provider make the decision to render services, the provider may require payment from the member. Providers may submit a claim to Health Net as well, but the claim will be contested and only paid if the member's eligibility status is returned to active status after all overdue premiums are paid in full.
  3. If the member subsequently pays his or her premium and is removed from a suspended status, claims will be adjudicated by Health Net. The provider is then responsible for reconciling any payment received from the member and the payment received from Health Net. The provider may then bill the member for an underpayment or return any overpayment to the member.
  4. If the member does not pay his or her premiums in full by the end of the three-month grace period and Health Net plan coverage is terminated, providers may bill the member for the full billed charges.

Verifying Eligibility for IFP Members

Providers are responsible for verifying benefits, eligibility and cost shares each time a member is scheduled to receive services. Presentation of a member identification (ID) card is not a guarantee of eligibility. Providers must always verify eligibility on the same day services are required. Member eligibility can be verified on the provider portal, as follows:

If the provider is serving:

Then the provider should:

  1. IFP CommunityCare HMO
  2. IFP EnhancedCare PPO
  3. IFP PureCare HSP
  4. PPO Individual and Family
  5. IFP PureCare One EPO

Verify member eligibility for IFP members through the Health Net provider portal at:

provider.healthnetcalifornia.com.

When verifying member eligibility on the Health Net provider portal, you must first select the appropriate product for each individual member or the member information will not be found. You must select the commercial product for commercial members (such as IFP members). If you do not select the appropriate product type for the specific member, the eligibility status will not display. Follow these simple steps:

Step

Action

Step 1

Log in to the provider portal at provider.healthnetcalifornia.com. Select product type (use the drop-down menu on top of the screen to choose Health Net Commercial - CA for IFP members), then select Go.

Step 2

Select the Eligibility tab or use Quick Eligibility Check on the main page.

Step 3

Enter the date of service only if it is other than today's date (disregard this step if using Quick Eligibility Check).

Step 4

Enter the complete member ID number as displayed on the member ID card or last name as displayed on the member ID card, and date of birth (DOB) in the applicable boxes for the specific member you are verifying. Points to be aware of on the member ID card:

  • Include the "R" ID number; use only the letter and numbers listed (R12345678) and do not use MM1 or FS1.
  • Include the full "U" ID number, as displayed with the first letter and all numbers listed (such as U1234567801 or U1234567802 as listed on the card).
  • If searching by last name, include the suffix, such as Jr., as listed on the member's ID card. Please remember to also include the DOB, since this is a required field, if searching by last name.

Step 5

Then select Check Eligibility. If the complete member ID and DOB were entered and this does not provide eligibility status for the specific member you are verifying, try using the last name and DOB instead.

When viewing eligibility of IFP members on the secure portal, providers will see a status message (PDF).

If the member status is not found on the Health Net provider portal at provider.healthnetcalifornia.com, then confirm that the member has an IFP plan. If the member has an employer group or small business group commercial plan, then verify member eligibility through the Health Net provider portal at provider.healthnet.com.

If the member's information is not found online, contact the applicable Health Net Provider Services Center.

Last Updated: 01/28/2020