Eligibility Verification Methods
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
When an individual seeks medical attention from a participating physician group (PPG), hospital or other provider, the provider must attempt to determine eligibility with Health Net before providing care.
Member eligibility is verified at the time that the identification (ID) card is issued; however, possession of the card does not guarantee eligibility. In cases where a member has lost an ID card or where eligibility may be in question, eligibility can be verified as follows:
Eligibility Reports (applies to capitated PPGs and hospitals). Refer to Use Eligibility Report to Verify Member Information in the Monthly Eligibility Reports section for more information.
- Online: Download the Save Time Navigating the Provider Portal (PDF) booklet for step-by-step instructions.
- The interactive voice response (IVR) system for employer group EPO, HMO, HSP and PPO members to obtain information on member eligibility, copayment and claims status.
- Refer to the IVRs available for Covered California and Individual Family Plan (IFP) members to obtain information on member eligibility, copayments and claims status.
- Eligibility verification via the provider's clearinghouse. Health Net is a Phase I- and Phase II-certified entity with the Council for Affordable and Quality Healthcare (CAQH) Committee on Operating Rules (CORE) for eligibility responses. Providers must contact their vendor/clearinghouse to submit transactions via this method using an EDI transaction or clearinghouse product.
Grace Period - Suspended Eligibility Status
A member's eligibility status may indicate that eligibility is suspended. Members who qualify for advanced premium tax credits (APTC) to subsidize his or her purchase of a health benefit plan through the Covered California marketplace are allowed an extended premium payment grace period of three months before the member's coverage is terminated. Refer to Premium Payment Grace Period for Beneficiaries Qualifying for APTC for additional information on member, provider and Health Net's rights when the member's eligibility is in suspended status during the first, second, or third month of the grace period.