Shared-Risk Claims

Shared-risk claims must be sent to Health Net or the affiliated health plan for adjudication. Additionally, the claims should be separated by plan or shared-risk services and claim types. All claims submitted to Health Net or Molina Healthcare must be on CMS-1500, LTC form 25-1, UB-92 or UB-04 claim forms and indicate the date of receipt by the participating physician group (PPG). Claims for plan or shared-risk services must be submitted to Health Net or Molina.

The following information must be included on every claim:

• Health Net member identification (ID) number or reference number, which is 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 U-92 (CMS-1450) revenue code
• Place of service or UB-92 or UB-04 bill type code
• Submitting provider tax identification number and national provider identifier (NPI) number
• Member name and date of birth as indicated on the member ID card
• State license number of the attending provider

If a claim is sent directly to Health Net or its affiliated health plans, rather than the capitated PPG, and the claim includes both plan risk services and capitated-risk services, the plans process the plan risk services. Claims for services that are the PPG's responsibility are forwarded to them for processing.

Claims for capitated services that are misrouted to Health Net or an affiliated health plan are routed back to the appropriate PPG.

In some instances, Health Net is able to split a claim that has both plan and capitated-risk services (for example, chemotherapy provider claims).