Claims Submission
Provider Type
- Participating Physician Groups (PPG)
To be reimbursed for AIDS-related claims through special risk reinsurance, participating physician groups (PPGs) must submit a Health Net Professional Batch form completed as follows:
- "Special Risk Reinsurance" must be written at the top of the form
- Attach CMS-1500 or UB-92 form, as follows:
- Original copies or a very clear photocopy
- Itemized bills attached to each inpatient claim
- Itemized bills attached to each electronic claim
- Attach a copy of the explanation of check, if applicable
- Attach copies of authorization for nuclear medicine claims
- Specify AIDS-related conditions on the form (refer to Attachment A (PDF) for a list of Centers for Disease Control and Prevention (CDC) diagnosis criteria)
- Attach a completed Attachment A for first time claim submissions in place of the member's medical records. Include date member was first diagnosed with AIDS (symptomatic HIV infection). Form must be signed by PPG staff member ensuring records review occurred and case met criteria for special risk reinsurance program
- Attach a completed Attachment B (PDF) for all subsequent claim submissions for the same member
- Do not highlight on the form
Health Net has modified requirements for submitting requested medical records with respect to member confidentiality concerns. Health Net no longer requires regular submission of the following items, but may request them in individual cases.
- Medical records and lab reports (for example, CD4T - Lymphocyte count and HIV test result only) for members not established in special risk reinsurance to determine whether criteria are met
- Copies of medical records with each subsequent claim submission when diagnosis on claim does not match the criteria matrix
- List of medications prescribed to member. Medications should match the procedures or examination charges
Claims Processing and Reimbursement
Claims are processed in accordance with Health Net's procedures and the Provider Participation Agreement (PPA). Health Net subtracts from the calculated resource-based relative value scale (RBRVS) payment any copayments allowed for the type of service and any third-party amounts collected by the PPG.
A PPG that believes an error has been made in a claim processing decision should contact Health Net's Claims Unit. PPGs may appeal the final settlement to Health Net management.
PPGs must submit claims to Health Net within the time frame specified in their PPA (generally 120 days). If a PPG submits claims for reimbursement past the timely filing limit specified in their PPA, Health Net denies reimbursement for these claims and the PPG has full responsibility for these services.