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Capitated Claims Billing Information

Provider Type

  • Physicians 
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

Providers who participate in Health Net's Medi-Cal program under a capitated agreement with a participating physician group (PPG) must follow the instructions below.

  • Providers must contact their PPG to check for any special billing requirements that the providers' failure to follow could delay the processing of their claims, and to verify the billing address for claims submission.
  • Providers have 180 days from the last day of the month of service to submit initial Medi-Cal claims. Exceptions for late filing are:
  • New Medi-Cal claims between six-months and one-year-old are permitted without penalty for unknown eligibility status, antepartum obstetric care or a delay in delivery of a custom-made prosthesis
  • Claims one-year-old or more are permitted without penalty for retroactive eligibility situations, court orders, state or administrative hearings, county errors in eligibility, Department of Health Care Services (DHCS) orders, reversal of appeal decisions on a Treatment Authorization Request (TAR) form, or if other coverage is primary

Capitated Risk Claims

Capitated-risk claims received by Health Net through paper submissions are forwarded back to the PPG or third-party administrator (TPA) for processing.

Electronically submitted claims that are participating physician group (PPG) capitated-risk claims are forwarded to the PPG or third-party administrator (TPA) for processing. A claim fax summary is printed, batched and forwarded. A batch trailer sheet, indicating the number of claims within a batch, is sent.

Denied Claims

Claims received by Health Net for services that are the capitated-risk of a participating provider are forwarded by Health Net to the appropriate capitated provider for processing. This may delay payment by several days to several weeks.

The Health Net Medi-Cal Claims Department sends a weekly report to any provider who has submitted claims to Health Net that are denied by Health Net as services capitated to a participating physician group (PPG) or hospital. The report provides the name and telephone number of the PPG or hospital to which the denied claims have been forwarded for processing.

The EOC 300/308 Report is generated using two explanation of check codes:

  • 300 - Service capitated to member's PPG, claim sent to PPG
  • 308 - Service capitated to facility, claim sent for processing

Denied claims with these EOC codes are grouped according to the capitated PPG or hospital responsible for the claim.

Field Descriptions

The following information correlates to the numbered fields on the Health Net EOC 300/308 Report (PDF) of denied capitated claims:

Header Information

# Field Description

1.

ABS

Health Net's operating system

2.

Program ID

Health Net's assigned number for the report

4.

Claim Type

Facility = UB-04 form

Professional = CMS-1500 form

4.

Report Title

The name of the report

5.

Run Date

The day/month/year that the report was generated

6.

Run Time

The time that the report was generated

7.

Page Number

The page number of the report

8.

Remit Num

A 14-digit internal number that gives information about the claim's financial status

9.

Check Date

The date of the check issued to a provider for claim payment

10.

Servicing Provider

The TIN and name of the provider who submitted the claim to Health Net for payment

11.

Pay To

The name of the group that the Servicing Provider is linked to. The Servicing Provider and Pay To can be the same

Detail Information

# Field Description

12.

Capped PPG/HOSP/PHONE

If a claim was denied on the explanation of check (EOC), then the name of the PPG or hospital where the claim was sent for processing would be listed here with the most current phone number that Health Net has on file

13.

Member ID

Health Net's member identification number

14.

MBR Last Name

The last name of the member

15.

MBR First Name

The first name of the member

16.

Claim Number

Health Net's 11-digit Document Control Number (DCN)

17

Beg DOS

The starting date of facility/professional services

18

End DOS

The ending date of facility/professional services

19.

PROC

The billed procedure code on the UB-04 or CMS-1500 claim (if services billed are revenue, this field is blank)

20.

DIAG

A three to seven character code based on the ICD-10 coding system, indicating the condition for which services on this claim were rendered

21.

EOC

A three-digit code appears on the provider's EOC explaining the action taken on this claim line. If a claim is coded with EOC 300 or 308, then the claim was denied to responsible capitated PPG or capitated facility for services rendered

300 = Service capitated to member's PPG, claim sent to PPG

308 = Service capitated to facility, claim sent for processing

22.

Billed Amt

The amount billed for a claim line

All provider inquiries about claim status, payment amounts, or denial reasons should be directed to the capitated provider responsible for the services.

Plan-risk or shared-risk claims must be sent to Health Net for adjudication. Attach a copy of the Plan/Shared-Risk Cover Sheet to each group of claims the provider submits. Additionally, the claims should be separated and batched into plan or shared-risk services and claim types. All claims submitted to Health Net must be on CMS-1500, LTC form 25-1 or UB-04 claim forms, and must indicate the date of receipt by the participating physician group (PPG). Claims for plan-risk or shared-risk services must be submitted to Health Net.

The following information must be included on every claim:

  • Health Net member identification (ID) number or reference number located on the member's ID card
  • Provider name and address
  • ICD-10 diagnosis code
  • Service dates
  • Billed charge per service
  • Current year CPT procedure or UB-04 revenue code
  • Place of service or UB-04 bill type code
  • Submitting provider tax identification number or National Provider Identifier (NPI) number
  • Member name and date of birth as it appears on the member's ID card
  • State license number of the attending provider

If a provider submits a claim directly to Health Net rather than the PPG and the claim includes both plan-risk services and capitated-risk services, Health Net processes the plan-risk services. Services that are the responsibility of the PPG are denied by Health Net and forwarded to the PPG for processing. The Explanation of Check contains the message, "Capitated services, no payment issued-claim sent to IPA, Hospital or Ancillary provider."

Claims for capitated services that are misrouted to Health Net are denied and forwarded to the capitated provider with a copy of the explanation.

In some instances, Health Net is able to split a claim that has both plan-risk and capitated-risk services (for example, chemotherapy provider claims). In these cases, a claim fax is attached to the original claim. The fax contains only those service lines that appear to be capitated-risk. The message "POSSIBLE CAP RISK" appears in the member's address field (box 4 on the fax). These services do not appear on the explanation of check, but appear on the capitated-risk services report.

All other lines on the original claim document are assumed to be plan-risk and are processed by Health Net. It is not necessary to return the claim for those plan-risk services not appearing on the fax.

If, after processing the services on the fax, the capitated provider determines that any of those services are actually plan-risk (for example, out-of-area emergency), return them to Health Net for special handling and processing. Attach the Plan/Shared Risk Services Cover Sheet and return those claims to Health Net.

Last Updated: 08/05/2021