Emergency Claims Processing
- Participating Physician Groups (PPG)
(does not apply to HSP)
Health Net, its participating physician groups (PPGs) and hospitals are required to reimburse each complete emergency claim or portion of each claim as soon as possible, but not later than 45 business days after receipt of the complete claim. A PPG or hospital may contest or deny a claim or portion of a claim by notifying the provider in writing that the claim is contested or denied within 45 business days after receipt of the claim. The notice must identify the portion of the claim that is contested by revenue code, and the specific information needed from the provider to reconsider the claim. The notice that a claim is denied must identify the portion of the claim that is denied, and the specific reasons for the denial.
If a claim or portion of a claim is contested on the basis that the PPG or hospital has not received information reasonably necessary to determine payer liability for the claim, the PPG or hospital has 45 business days after receipt of this additional information to complete reconsideration of the claim. If the claim being reconsidered is not reimbursed within the respective 45 business days after the PPG's or hospital's receipt of the additional information, the PPG or hospital must pay interest or late charges.
A PPG or hospital may delay payment of an uncontested portion of a complete claim for reconsideration of a contested portion of that claim as long as the PPG or hospital pays interest.
Complete Emergency Claims
A complete emergency claim meets the following definitions:
- A paper claim from a hospital is deemed complete when submitted on a completed UB-04 and includes submission of a legible emergency room (ER) report and other reasonable relevant information requested.
- An electronic claim from a hospital is deemed complete when submitted on an electronic equivalent to the UB-04 and reasonable relevant information is requested. If Health Net or the PPG requests a copy of the ER report, Health Net or the PPG may also request additional reasonable relevant information, at which time the claim is deemed complete.
- A claim from a provider is deemed complete when submitted on a completed CMS-1500, or its electronic equivalent, and reasonable relevant information is requested.
The obligations of Health Net, to ensure that claims are processed in a timely manner and with appropriate interest and late charges, if appropriate, are not waived when Health Net requires its PPGs to pay claims for covered services. Health Net may assign, by written contract, the responsibility to pay interest and late charges to PPGs or other contracting entities.
Interest Charged for Late Payment
The late payment by a PPG or hospital on a complete emergency claim, or portion thereof, that is neither contested nor denied, must automatically include the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at 15 percent per year for the period of time that the payment is late. If the late payment does not automatically include interest, an additional $10 is paid to the provider.
If Health Net fails to notify the provider of service in writing of a denied or contested claim, or portion thereof, and ultimately pays the claim in whole or part, computation of the interest begins 45 business days after the date the claim was originally received.
Payment of interest or late charges does not apply to claims where there is evidence of fraud and misrepresentation, where the patient is determined to be ineligible for coverage, or instances where Health Net has not been granted reasonable access to information under the provider's control. Health Net specifies, in a written notice sent to the provider within the 45-business-day time frame, which of these exceptions apply to the claim.