Timely Filing Criteria
- Participating Physician Groups (PPG)
(does not apply to HSP)
If a claim is denied for timely filing, but the provider can demonstrate good cause for the delay, Health Net accepts and adjudicates the claim as if it were submitted in a timely manner. The Health Net Provider Appeals Unit considers and makes the determination of whether or not there is a good cause for the delay. Health Net has standardized guidelines for showing good cause for delay and goodwill adjustments.
Good Cause for Delay Guidelines
Good cause for delay applies for providers who received misinformation from members or Health Net that caused timely filing claim denials and can demonstrate good cause for claim submission delays within the guidelines below:
- The delay was not reasonably in the provider's sole ability to control. For example: The provider received misinformation from the member and the provider is submitting one of the following:
- Patient information form and/or member identification (ID) card presented by the Health Net member.
- Explanation of benefit (EOB) from incorrect carrier and/or participating physician group (PPG).
- The provider has followed Health Net instructions.
- Circumstances existed that the provider could not foresee or prevent.
- The length of the delay was such that it was unreasonably difficult or impossible for the provider, in the normal course of business, to file the claim in a timely manner.
- The delay was not the result of the provider's negligent or willful action or inaction.
Other Adjustments Guidelines
For providers who can show proof of claim timely filing, Health Net gives consideration to other provider claim adjustments. The other adjustment policy guidelines are as follows:
- The provider submits proof in the form of one of the following:
- Electronic data interchange (EDI) confirmation that Health Net received and accepted the claim.
- Delivery confirmation evidence (for example, registered receipt or certified mail receipt to a Health Net address).
- Screen print from accounting software to show the date the claim was submitted.