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Overview

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

Coordination of benefits (COB) is required before submitting claims for members who are covered by one or more health insurers other than Medi-Cal. Medi-Cal is always the payer of last resort, including Medicare and TRICARE.

Submission of a COB Claim

Coordination of benefits (COB) claims must be submitted within 180 days following the date that the member and provider receive the other coverage's Explanation of Benefits (EOB).

When the provider learns that a Health Net Medi-Cal member has other group health coverage, the provider must:

  • File the provider claim with the primary carrier first
  • After the primary carrier has paid, submit a copy of the explanation of check or EOB with the claim to Health Net or the responsible capitated subcontractor, if one exists

Payment Calculations

As the payer of last resort, Health Net's Medi-Cal plan coordinates benefits. In order for Health Net to document records and process claims correctly, include the following information on all coordination of benefits (COB) claims:

  • Name of the other carrier
  • Subscriber identification number with the other carrier

Dual Health Net coverage refers to members that are covered under two Health Net plans. Claims must be submitted to the primary plan first. The Health Net Medi-Cal plan is the secondary coverage under coordination of benefit (COB) rules. The secondary claim must be submitted with the primary Health Net remittance advice, identification and group numbers, indicating the primary Health Net identification number in the Other Coverage box.

Last Updated: 08/05/2021