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20-092 Prior Authorization Requirements
20-264 Improve Your Access and Availability
20-317 Disease Management Transitioning from Optum to Health Net Integrated Care Management on March 15, 2020
20-408 Use These Guidelines to Improve Trauma-Informed Care for Patients with ACEs
20-465 Changes and Clarifications to Reject Codes 76, AK and C6
20-506 Learn How to Bill ACEs Screening HCPCS Codes G9919 and G9920
20-508 Learn How to Bill ACEs Screening HCPCS Codes G9919 and G9920
20-561 Review New Requirements for Private Duty Nursing for Medi-Cal Members Under Age 21
20-513 Start with Primary Care to Manage High-Risk-Opioid Use
20-963 State of Emergency: Mountain View Fire in Mono County
21-701 The New Provider Portal is Launching Soon!
21-129 Offer 24-Hour Non-Emergency Medical Transportation to Medi-Cal Members Who Need a Ride to Pharmacies and Urgent Care (Dual Risk)
22-060 State of Emergency Due to Winter Storms in Trinity County
22-474 Materials Required in Alternative Formats Based on Member Request
22-726 Monkeypox: Learn About Symptoms, Where to Test and How to Treat
23-346m Bill Correctly to Get Paid for Primary Diagnosis and Interim Claims Submitted
Contacts
AcariaHealth
Access2Care
Access to Interpreter Services
AIDS Waiver Program
Alcohol and Drug Treatment Services
American Specialty Health Plans
Animas Diabetes Care LLC
Apria Healthcare Inc
ATG Rehab Specialists Inc
Byram Healthcare Centers, Inc.
Cal MediConnect Appeals and Grievances Department
Cal MediConnect Member Services Department
Cal MediConnect Provider Services Center
California Children's Services Program
California Children's Services Paneling Inquiries
California Department of Social Services State Fair Hearing
CalViva Health Medi-Cal Member Services Department
CalViva Health Medi-Cal Provider Services Center
CalViva Health Nurse Advice Line
Cancer Information Services
Case Management Department
Centers for Medicare & Medicaid Services
Centralized Transplant Unit
Child Health And Disability Prevention Program
Children's Medical Services
Communicable Disease Reporting
Community-Based Adult Services Centers
Community-Based Adult Services Face-To-Face Request Line
Comprehensive Perinatal Services Program
Connect Hearing Inc
Coram CVS
Custom Rehab Network
County Mental Health Plan
Denti-Cal
Department Of Health Care Services
Department of Insurance
Department Of Managed Health Care
Department Of Social Services (DSS)
Electronic Claims Clearinghouse Information
Envolve Vision
EviCore Healthcare
EyeMed Vision Care
Financial Oversight Department
Health Care Options (HCO)
Health Net Cal MediConnect Claims Department
Health Net Care Management Department
Health Net CHDP PM160 INF Forms
Health Net Claims Submission
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Health Net Decision Power Referral Fax
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Chemotherapy
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Clinical Trials
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Dental Services
Dialysis
Durable Medical Equipment
Enteral Nutrition
Family Planning
General Benefit Exclusions and Limitations
Hearing
HIV Testing and Counseling
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Initial Health Appointment
Injectables
Maternity
Medical Social Services
Nurse Midwife
Obesity
Outpatient Services
Physicians Visit
Podiatry
Post Stabilization
Preventive Services
Prosthesis
Rehabilitation Therapy
Respite Care
Routine Physical Exam
Second Opinion by a Physician
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Transportation
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility and Capitation
Eligibility Guarantee
Fee-For-Service Billing and Submission
Institutionalized Members
Medicare Risk Adjustment Report
Payment for Service of Non-Participating Providers
Professional Claim Editing
Professional Stop Loss
Provider Participation Agreement
Refunds
Reimbursement
Reinsurance
Schedule of Benefits
Shared Risk
When Medicare is a Secondary Payer
Claims Coding Policies
Code Editing
Payment Integrity Policies
Compliance and Regulations
Medicare Communications and Marketing Guidelines
Provider Offshore Subcontracting Attestation
Approval of Medicare Communications and Marketing Guidelines
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
COB Payment Calculations
Determination of Primary Insurer
Medicare Plus (Plan J or HJA)
Recovery of Excessive Payments
The Plan's Right to Pay Others
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Collection of Copayments for Referrals
Collection of Medicare Copayments
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
Claims Denial Requirements
Denial of Investigational or Experimental Treatment for a Terminal Illness
Service Denial Templates
Integrated Denial Notification - Notice of Denial Medical Coverage Template Information
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notification Delays
Requirements for Notification of Utilization Management Decisions
Disenrollment
Appeals, Grievances and Disputes
Expedited Reviews
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Eligibility
COBRA Continuation
Dual-Eligible Medicare Beneficiaries
Steps to Determine Eligibility
Eligibility Reports
Eligibility Reports
Health Net Medicare Advantage Capitation Eligibility Summary Reports by Group and Provider
Health Net Medicare Advantage Reconciliation Report
Emergency Services
Coverage Explanation
Additional Monitoring Responsibilities
Instructions to Members Regarding Authorization
Out-of-Area Emergency or Urgently Needed Care
PPG Responsibilities
Encounters
Overview
Dual-Risk Contracts Encounter Data Submission
Encounter Reporting
Error Notification
Institutional Encounter Data Submission Requirements
Lien Recoveries
Noncompliance with Encounter Data Submission
Professional Encounter Submission Requirements
Enrollment
Annual Election and Enrollment Periods
Member Enrollment
Part D Enrollment
Subscriber and Member Identification Numbers
Use of Social Security Numbers
Administration of New Member Procedure
Conditions for Transfer Between PPGs
Member Terminations
ID Cards
Member ID Card
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Confidentiality of Medical Records
Medical Record Documentation
Medical Record Forms and Aids
Confidentiality of Medical Records
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Medicare Advantage Part B
Accessing Part D Prescription Medications
Compounded Medications
Coverage Explanation
Generic Medications
Medication Therapy Management Program
Participating Pharmacy
TransactRx
Prior Authorizations
Overview
Authorization for Admission to Hospital or SNF
Diagnostic Procedures
How to Secure Prior Authorization on the Provider Portal
PPGs' Responsibilities for Authorization
Prior Authorization Process for Direct Network Practitioners
Product Descriptions
Medicare Select Plan Description
Medicare Plans
Optional Supplemental Benefits Package
Provider Oversight
Overview
Calendar of Required PPG Submissions
Corrective Action Plan
Fraud, Waste and Abuse
Member Appeals and Grievances
Monitoring Provider Exclusions
Special Needs Plan Model of Care
Subdelegated Functions
Contractual Financial and Administrative Requirements
Delegated Medical Management
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Disease Management Programs
Health Education Program
Health Management Programs
Language Assistance Program and Cultural Competency
Quality Improvement Program
Referrals
Overview
Direct Network Referral Process
Investigational and Experimental Treatment
OB/GYN Self-Referrals
Out-of-Network Referrals
Post-Stabilization Care
Role of the Primary Care Physician
Self-Referral Benefits
Third-Party Liability
Coverage Explanation
Urgent Care
Utilization Management
Overview
Affirmative Statement About Incentives
Availability of Criteria
Care Management
Clinical Criteria for Medical Management Decision Making
Continuity of Care
Coverage Determination
Health Risk Assessment
Medical Data Management Reporting
Medical Data Management System
Medicare Certified Facilities
Non-Delegated Medical Management
Notification of Hospital Admissions
Notification of Hospital Discharge Appeal Rights
Out-of-Area Services
Separation of Medical Decisions and Financial Concerns
Termination of Provider Services
Utilization Management Goal
Utilization Management Program Components
Special Supplemental Benefits for Chronically Ill Attestation
Participating Physician Group (PPG) Performance Scorecard
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Provider Pulse Newsletter
Contacts
Glossary
Quality Management Program and Resources
Cal MediConnect
COVID-19 Provider Alerts
D-SNP
Provider Manual
Adverse Childhood Experiences (ACEs)
Benefits
Overview
Access to Sensitive Services
AIDS
Alcohol and Drug Abuse
Acupuncture
Allergy Treatment
Ambulance
Bariatric Surgery
Behavioral Health
Blood
Chemotherapy
Coverage Explanation
Chiropractic
Clinical Trials
Complementary Supplemental Benefits
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Durable Medical Equipment
Enteral Nutrition
Family Planning
General Benefit Exclusions and Limitations
Hearing
HIV Testing and Counseling
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Incontinence
Initial Health Assessment
Injectables
Long-Term Care
Medical Social Services
Nurse Midwife
Obesity
Outpatient Services
Physicians Visit
Podiatry
Post Stabilization
Preventive Services
Prosthesis
Rehabilitation Therapy
Respite Care
Respite Care for Care Plan Option
Routine Physical Exam
Second Opinion by a Physician
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Transportation
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility and Capitation
Eligibility Guarantee
Fee-For-Service Billing and Submission
Institutionalized Members
Medicare Risk Adjustment Report
Payment for Service of Non-Participating Providers
Professional Stop Loss
Provider Participation Agreement
Refunds
Reimbursement
Reinsurance
Shared Risk
Claims Coding Policies
Payment Integrity Policies
Provider-Preventable Conditions
Compliance and Regulations
Medicare Communications and Marketing Guidelines
Provider Offshore Subcontracting Attestation
Approval of Medicare Communications and Marketing Guidelines
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
Determination of Primary Insurer
The Plan's Right to Pay Others
Copayments
Cal MediConnect Copayments
Collection of Copayments for Referrals
Collection of Medicare Copayments
Verifying and Clearing Share-of-Cost
Credentialing
Application Process
Site Evaluations
Denial Notification
Claims Denial Requirements
Denial of Investigational or Experimental Treatment
Integrated Denial Notification - Notice of Denial Medical Coverage Template Information
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notification Delays
Requirements for Notification of Utilization Management Decisions
Disenrollment
Appeals, Grievances and Disputes
Expedited Reviews
Member Appeals
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Eligibility
Eligibility Criteria for Cal MediConnect
Dual-Eligible Medicare Beneficiaries
Steps to Determine Eligibility
Eligibility Reports
Eligibility Reports
Eligibility Reports
Health Net Medicare Advantage Capitation Eligibility Summary Reports by Group and Provider
Health Net Medicare Advantage Reconciliation Report
Emergency Services
Coverage Explanation
Additional Monitoring Responsibilities
Instructions to Members Regarding Authorization
Out-of-Area Emergency or Urgently Needed Care
PPG Responsibilities
Encounters
Overview
Dual-Risk Contracts Encounter Data Submission
Encounter Reporting
Error Notification
Institutional Encounter Data Submission Requirements
Lien Recoveries
Noncompliance with Encounter Data Submission
Professional Encounter Submission Requirements
Enrollment
Annual Election and Enrollment Periods
Member Enrollment
Part D Enrollment
Subscriber and Member Identification Numbers
Use of Social Security Numbers
Administration of New Member Procedure
Conditions for Transfer Between PPGs
Member Terminations
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medi-Cal and Cal MediConnect Medical Records Reviews
Medical Record Documentation
Medical Record Forms and Aids
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Medicare Advantage Part B
Accessing Part D Prescription Medications
Cal MediConnect Coverage Explanation
Compounded Medications
Generic Medications
Medication Therapy Management Program
Participating Pharmacy
Prescription Mail-Order Program
Recommended Drug List and Cal MediConnect Formulary
TransactRx
Prior Authorizations
Overview
How to Secure Prior Authorization on the Provider Portal
Notification of Inpatient Admissions
PPGs' Responsibilities for Authorization
Product Descriptions
Cal MediConnect
Provider Oversight
Overview
Calendar of Required PPG Submissions
Corrective Action Plan
Fraud, Waste and Abuse
Member Appeals and Grievances
Monitoring Provider Exclusions
Subdelegated Functions
Contractual Financial and Administrative Requirements
Delegated Medical Management
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Public Programs
Long-Term Services and Supports
Tuberculosis Detection and Treatment
Quality Improvement
Disease Management Programs
Facility Site Review
Health Education Program
Health Management Programs
Language Assistance Program and Cultural Competency
Medi-Cal and Cal MediConnect Quality Improvement Programs
Health Education
Quality Improvement Program
Referrals
Coverage Explanation
Continuity of Care
Investigational and Experimental Treatment
OB/GYN Self-Referrals
Out-of-Network Referrals
Post-Stabilization Care
Third-Party Liability
Overview
Provider Responsibilities
Urgent Care
Utilization Management
Overview
Care Management
Clinical Criteria for Medical Management Decision Making
Continuity of Care
Coverage Determination
Health Risk Assessment
Medical Data Management Reporting
Medical Data Management System
Notification of Hospital Admissions
Notification of Hospital Discharge Appeal Rights
Out-of-Area Services
Separation of Medical Decisions and Financial Concerns
Utilization Management Goal
Utilization Management Program Components
Updates and Letters
Forms and References
Education, Training and Other Materials
Health Equity, Cultural and Linguistic Resources
Contacts
Glossary
Quality Management Program and Resources
EPO
COVID-19 Provider Alerts
Provider Manual
Adverse Childhood Experiences (ACEs)
Benefits
Acupuncture
Alcohol and Drug Abuse
Allergy Treatment
Ambulance
Autism Spectrum Disorders
Bariatric Surgery
Behavioral Health
Blood
Chemotherapy
Chiropractic
Clinical Trials
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Durable Medical Equipment
Essential Health Benefits
Family Planning
General Benefit Exclusions and Limitations
Genetic Testing
Hearing
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Injectables
Maternity
Medical Social Services
Nuclear Medicine
Obesity
Outpatient Services
Periodic Health Evaluations
Physicians Visit
Preventive Services
Prosthesis
Rehabilitation Therapy
Routine Physical Exam
Second Opinion by a Physician
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Compliance for Transplant Performance Centers Standardized Process
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility and Capitation
Eligibility Guarantee
Fee-For-Service Billing and Submission
Professional Claim Editing
Refunds
Reimbursement
Salud con Health Net
Schedule of Benefits
Timely Filing Criteria
When Medicare is a Secondary Payer
Claims Coding Policies
Code Editing
Payment Integrity Policies
Compliance and Regulations
Provider Offshore Subcontracting Attestation
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
The Plan's Right to Pay Others
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Calculation of Coinsurance
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
Service Denial Templates
Member Denial Letter Templates
Required Elements for Provider Notification Letters
Requirements for Notification of Utilization Management Decisions
Appeals, Grievances and Disputes
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Eligibility
Extension of Benefits
Provider Responsibility for Verifying Eligibility for On-Exchange IFP Members in Delinquent Premium Grace Period
Steps to Determine Eligibility
Emergency Services
Overview
Additional Monitoring Responsibilities
Instructions to Members Regarding Authorization
Out-of-Area Emergency or Urgently Needed Care
Encounters
Overview
Encounter Reporting
Lien Recoveries
Enrollment
Subscriber and Member Identification Numbers
Use of Social Security Numbers
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medical Record Documentation
Medical Record Forms and Aids
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Compounded Medications
Diabetic Supplies
Exclusions and Limitations
Generic Medications
Off-Label Medication Use
Participating Pharmacy
Physician Self-Treatment
Prescription Mail-Order Program
Prior Authorization Process
Quantity of Medication to Be Prescribed
Recommended Drug List and Cal MediConnect Formulary
Prior Authorizations
How to Secure Prior Authorization on the Provider Portal
NIA - Prior Authorization
Prior Authorization Process for Direct Network Practitioners
TurningPoint
Product Descriptions
Primary EPO Plan Overview
Provider Oversight
Fraud, Waste and Abuse
Monitoring Provider Exclusions
Contractual Financial and Administrative Requirements
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Disease Management Programs
Health Education Program
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Family Planning
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Genetic Testing
Hearing
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Injectables
Maternity
Medical Social Services
Nuclear Medicine
Nurse Midwife
Outpatient Services
Periodic Health Evaluation
Preventive Services
Prosthesis
Rehabilitation Therapy
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Vision
X-Ray and Laboratory Services
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility Guarantee
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Fee-For-Service Billing and Submission
Premium Payment Grace Period for Beneficiary Qualifying for APTC
Professional Claim Editing
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Reinsurance
Schedule of Benefits
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Code Editing
Payment Integrity Policies
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Communicable Diseases Reporting
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Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
COB Payment Calculations
Disagreements with Other Insurers
Duplicate Plan Coverage
Medicare Plus (Plan J or HJA)
Order of Benefit Determination
Recovery of Excessive Payments
Services Instead of Cash Payments
The Plan's Right to Pay Others
TRICARE/CHAMPVA
Veterans' Administration
When the Plan is the Primary Carrier
When the Plan is the Secondary Carrier
Copayments
Calculation of Coinsurance
Collection of Copayments
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
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Denial of Investigational or Experimental Treatment for a Terminal Illness
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Hearing
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Incarcerated Members
Maternity
Medical Social Services
Nuclear Medicine
Nurse Midwife
Obesity
Outpatient Services
Periodic Health Evaluations
Preventive Services
Prosthesis
Rehabilitation Therapy
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
TMJ
Transgender Services
Transplants
Vision
X-Ray and Laboratory Services
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Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
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Code Editing
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Provider Offshore Subcontracting Attestation
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
Coordination of Benefits
Overview
COB Payment Calculations
Disagreements with Other Insurers
The Plan's Right to Pay Others
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Verify Copayments
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Compounded Medications
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Exclusions and Limitations
Generic Medications
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Participating Pharmacy
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Last Updated: 05/25/2022
