Collection of Copayments
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Participating providers collect copayments for professional services when services are provided. If immediate collection of a copayment is not possible, the provider must send a bill to the member for the copayment at a later date.
The participating provider may not impose a surcharge on a Health Net member for covered services provided. If Health Net receives notice of any surcharge, action is taken in response.
Collect required office visit copayments when a member is seen by a physician, physician assistant (PA), nurse practitioner (NP), or any qualified professional provider for basic medical care. Refer to the member's plan chart in the Schedule of Benefits for specific copayment information and additional guidance or a list of sample situations that may be useful in determining the appropriate type and number of copayments. A copayment must be collected according to the service provided and not according to the licensure of the professional providing the service. This underlying principle must be considered when determining whether an office visit copayment is required.
Participating providers may not collect a copayment or any other fees for a missed appointment. The provider has the option of having the member transferred to another participating provider after three missed appointments.
Primary Care Physician and Specialist Copayments
A service rendered by any provider type other than the member's assigned primary care physician (PCP) may have a separate and different copayment amount. The specialist office visit copayment is required each time the member receives services from the specialist (not limited to the first visit).
When a member receives services from a PA or NP for a PCP office visit, the PCP office visit copayment applies. When a member receives services from a PA or NP certified in a particular specialty, the specialist office visit copayment applies. If the member's PCP or any PCP from the member's participating physician group (PPG) provides services, the PCP copayment is applied. Refer to the specific plan chart for copayment amounts.
Urgent Care Copayment
The copayment amount due for care at an urgent care facility owned and operated by the member's PPG is the applicable office visit copayment instead of an urgent care copayment. This provision is reflected in the member's Evidence of Coverage (EOC).