Emergency Claims

Health Net, and its delegated and capitated participating physician groups (PPGs) and hospitals (payers), are required to reimburse, deny or contest each complete emergency claim or portion of each claim as soon as practical, but not later than 45 business days after receipt of the complete claim. Payers may contest or deny a claim or portion of a claim by notifying the provider in writing that the claim is contested or denied within 45 business days after receipt of the claim. If a claim is contested, the notice must identify the portion of the claim that is contested by revenue code, and the specific information needed from the provider to reconsider the claim. The notice that a claim is denied must identify the portion of the claim that is denied, and the specific reasons for the denial.

If a claim or portion of a claim is contested on the basis that a payer has not received information reasonably necessary to determine payer liability for the claim, the payer has 45 business days after receipt of this additional information to complete reconsideration of the claim. If reconsideration of the claim (including payment, if appropriate), is not completed within the respective 45 business days after the payer's receipt of the additional information, the payer must pay statutory interest and any other applicable penalties described in California Health and Safety Code section 1371.35(b).

Complete Emergency Claims

A complete emergency claim is defined as follows:

• A paper claim from a provider is deemed complete when submitted on a completed UB-04 and includes submission of a legible emergency room (ER) report and other reasonable relevant information requested
• An electronic claim from a provider is deemed complete when submitted on an electronic equivalent to the UB-04 and other requested reasonable relevant information has been received. If the payer requests a copy of the ER report, the payer may also request additional reasonable relevant information
• A claim from a provider is deemed complete when submitted on a completed CMS-1500, or its electronic equivalent, and any requested reasonable relevant information has been received

Delegation

The obligations of Health Net to ensure compliance with claims settlement laws are not waived when Health Net contracts with delegated and capitated PPGs or hospitals that agree to assume risk and pay claims for covered services.

Interest Charged for Late Payment

A payer's late payment of a complete emergency claim, or portion thereof, that is neither contested or denied, must automatically include the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at 15 percent per year for the period of time that the payment is late. If the late payment does not automatically include interest, an additional $10 is paid to the provider of service.

If the responsible payer fails to notify the provider of service in writing of a denied or contested claim, or portion thereof, and ultimately pays the claim in whole or in part, computation of the interest begins 45 business days after the date the claim was originally received.

Exceptions

Payment of interest or late charges does not apply to claims where there is evidence of fraud and misrepresentation or instances where a payer has not been granted reasonable access to information under the provider's control. Health Net specifies, in a written notice sent to the provider within the 45-business-day time frame, which of these exceptions apply to the claim.