The request for a 15-day letter is initiated when a Health Net member or provider has not been able to resolve a claim/ payment with the capitated Facility or the Participating Provider Group (PPG) for covered benefits. The servicing provider that is requesting the 15-day letter is required and responsible for providing all supporting documentation, including proof of timely filing when submitting claims with overdue payment for dates of service.

The plan advises its capitated providers to respond within 15 working days of the date listed on the 15-day letter about the disposition of the claim(s) so the plan may inform their member and servicing provider of the resolution. Any payment to the servicing provider must include a corresponding Explanation of Benefits (EOB) from the payee at risk.

If the capitated Facility or the Participating Provider Group (PPG) fails to respond to the 15-day letter or if the claim is not resolved satisfactorily within the time frame specified, the plan pays the claim and deducts the payment from the capitated provider's capitation check the following month.

Capitated providers are asked to produce a corrective action plan if the volume of 15-day letters exceeds the number permitted by the plan for more than three months. Capitated providers may be sanctioned if the volume of 15-day letters continues to exceed 0.2 percent of its enrollment by line of business. Sanctions may include freezing new enrollment and may ultimately result in termination of the capitation contract. Capitated providers are also advised by the Health Plan to check their capitation payments monthly for any capitation deductions to ensure that each 15-day letter(s) was received in the appropriate location or department for processing.