Shared-Risk Reporting
Provider Type
- Participating Physician Groups (PPG)
At the end of each month, all claim payments made by Health Net to treating providers (reconciliation claims) in that month are listed on the CLRM02S-ICE Shared-Risk Paid Claims Report and the Actuarial Injectable Risk Report is available on the provider portal websites > Reports under Welcome.
These reports list each reconciliation claim that Health Net paid using funds from the participating physician group's (PPG's) shared-risk budget. The CLRM02S-ICE report does not take into account the terms of specific individual Provider Participation Agreements (PPAs).
Health Net also provides the PPG with electronic monthly shared-risk reports within 60 days following the end of the month that is being reported. Health Net also provides the PPG with shared-risk status reports showing an estimated mid-year settlement within 90 days following the end of the first six months of the calendar year.
CLRM02S-ICE Version Shared-Risk Paid Claims Report Dispute
If a PPG feels that a claim was charged erroneously to the shared-risk budget, the PPG must document the charges in question (subscriber identification number, member's name, dates of service, amount paid, and other necessary information) and send this information to the Health Net Research and Resolution Unit within 90 days from the date the payment by Health Net was first reported to the PPG.
Actuarial Injectable Risk Report Dispute
If a PPG feels that a claim was charged erroneously to the shared-risk budget, the PPG must document the charges in question (subscriber identification number, member's name, dates of service, amount paid, and other necessary information) and send this information to the PPG's provider network representative within 90 days from the date of payment.
Paid Claims Report Field Descriptions
Field descriptions for the shared-risk paid claims report are contained in the CLRM02S-ICE Report located on provider portal websites > Reports under Welcome.