15-Day Letters

If Health Net or its affiliated health plans receive a balance bill from a member who is being balance billed by a provider for services that are a capitated provider's financial responsibility, Health Net asks the capitated provider to process the claim on a priority basis. This request is referred to as a 15-day letter.

If the capitated provider 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.

The plan advises its capitated providers to call the billing provider immediately upon receipt of such a request and inform the provider that it must cease any further balance-billing activity. This is also an opportunity to give the billing provider the correct claims submission address and explain any billing requirements.

Capitated providers are also advised to check their capitation payments monthly for these deductions, and ensure that each of the letters was received in the appropriate location or department for processing.