Billing and Authorization Procedures for Non-Benefit Codes
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Under current Medi-Cal policy, certain HCPCS and CPT codes may be listed as “non-benefit” and are not reimbursed under the standard Fee-for-Service (FFS) system. These codes are automatically denied unless deemed medically necessary and approved through prior authorization (PA).
Provider Responsibilities
- Verify code status – Providers must verify whether a billing code is listed as “non-benefit” by consulting the Medi-Cal Treatment Authorization Request (TAR) and Non-Benefit list.
- Prior authorization requirements:
- Providers must review Health Net’s or the delegated participating physician group’s (PPG’s) prior authorization requirements list before rendering services.
- If required, obtain PA before the service is provided. Failure to obtain required authorization may result in claim denial.
Claims Submission Guidelines
- If PA is required and approved – Submit the claim with the authorization number clearly indicated on the claim form.
- If PA is not required – Submit the claim using standard procedures.
Denied Claims and Dispute Resolution
If a claim is denied due to a “non-benefit” code and the provider believes the service should be covered:
- Initiate a provider dispute resolution (PDR) through Health Net or the delegated PPG.
- Include supporting documentation demonstrating medical necessity and any relevant authorization details.
PPGs Compliance
All delegated PPGs responsible for utilization management and claims payment must ensure their internal processes align with DHCS policy and Health Net requirements.