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Eligibility Guarantee

Provider Type

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

Eligibility guarantee is a payment of the amount agreed upon by Health Net and the capitated participating physician group (PPG) for payment of claims for services performed in good faith by any participating provider for a member who is later determined to have been ineligible on the date of service. In these cases, Health Net is liable up to the limits set forth in the PPG's Provider Participation Agreement (PPA) for the care provided before Health Net notifies the PPG of the member's ineligibility due to the retroactive addition or cancellation of the member. Unless otherwise specified in the PPG's PPA, the terms of the eligibility guarantee program are described below.

The eligibility guarantee does not apply if the PPG does not verify eligibility with Health Net for members who are receiving continuing services and who do not appear on the eligibility report (PPG and hospital only) within 60 days after the initial visit.

If a member is ineligible due to a retroactive addition or cancellation, Health Net adjusts the PPG's or hospital's capitation accordingly. 

For more information, select any subject below:

Last Updated: 03/12/2021