Balance Billing

Provider Type

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

Balance billing is strictly prohibited by state and federal law and Health Net's Provider Participation Agreement (PPA).

Balance billing occurs when a participating provider bills a member for fees and surcharges above and beyond a member's copayment and coinsurance responsibilities for services covered under a member's benefit program, or for claims for such services denied by Health Net or the affiliated participating physician group (PPG). Participating providers are also prohibited from initiating or threatening to initiate a collection action against a member for non-payment of a claim for covered services. Participating providers agree to accept Health Net's fee for these services as payment in full, except for applicable copayments, coinsurance, or deductibles.

Cal MediConnect and Dual Special Needs Plan (D-SNP) members are not subject to copayments, so providers must not charge Cal MediConnect or D-SNP members coinsurance, copayments, deductibles, financial penalties, or any other amount due to their Medi-Cal eligibility. Any amounts non-covered by the Medicare payment/reimbursement must be sent for secondary payment to the member’s Medi-cal managed care plan (MCP) or directly to the Department of Health Care Services (DHCS) if not assigned to a Medi-cal MCP for that date of service.

Providers can verify the member’s Medi-cal MCP by checking the Medi-Cal Automated Eligibility Verification (PDF) .

Providers can refer to the Verifying and Clearing Share-of-Cost section for information regarding Cal MediConnect or D-SNP members' share of cost (SOC) responsibility for certain services.  

Participating providers may bill a member for non-covered services when the member is notified in advance that the services to be provided are not covered and the member, nonetheless, requests in writing that the services be rendered. A participating provider who exhibits a pattern and practice of billing members will be contacted by Health Net and is subject to disciplinary action.

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