Administration of New Member Procedure

Provider Type

  • Participating Physician Groups (PPG)

A new member may require medically necessary services before receiving their identification (ID) card. Health Net has developed the following standard new member procedure:

  • Health Net charges applicable hospital fees to the member's selected participating physician group's (PPG's) shared risk. If the PPG finds a hospital claim has been erroneously added to the monthly Shared Risk Report after the member has been retroactively canceled, the PPG must notify the Health Net auditor in writing to remove the claim from the Shared Risk Report.
  • Health Net pays professional charges administratively. If the PPG has determined eligibility by the member's ID card, Enrollment form, Eligibility Report, Eligibility Certification form, or a telephone call to Health Net and care is provided to an ineligible patient, Health Net is liable for any professional care provided prior to notification of the patient's ineligibility.

Health Net verifies eligibility guarantee requests for reimbursement for professional services provided in the hospital or emergency room. Health Net then determines whether eligibility was given to the PPG.

A member ID card is not a guarantee of eligibility; therefore, the PPG must always contact the Health Net Provider Services Department (commercial HMO or Medicare Advantage) to verify eligibility prior to rendering services. PPGs retain a copy of the fax-back confirmation. If speaking directly with a representative, the PPG must also include the date the PPG called Health Net for verification of eligibility and the name of the representative.

Members must re-establish eligibility with Health Net for any services provided 60 days after the initial visit if the member still does not appear on the Eligibility Report.