- Participating Physician Groups (PPG)
Eligibility Reports provide information about member assignment to participating physician groups (PPGs) and hospitals (when applicable) for members enrolled in all lines of business.
Health Net generates Eligibility Reports twice a month, on approximately the first and the fifteenth. Reports generated at the beginning of the month reflect member eligibility as of the first of the month. Reports generated mid-month include any retroactive member eligibility to date.
Other health coverage information
Medi-Cal managed care plans (MCPs) are required to be the payer of last resort for services when a member has other health care coverage (OHC). PPGs can access the necessary OHC information on PPGs Capitation Eligibility Report ACE_RPT_BRM_42P SEQ. The reports will help PPGs to correctly identify OHC and avoid unnecessary costs.
Do not process claims for a member whose Medi-Cal eligibility report indicates OHC, other than an OHC code of A or N, unless the provider presents proof that all sources of payment have been exhausted, or the provided service meets the requirement for billing Medi-Cal directly.
To obtain OHC activity, refer to the report sections below:
- Detail Record: Provides member information.
- COB Record: Provides OHC demographic information.
When a claim is denied due to the presence of OHC, the minimum OHC information in your notifications to providers must include, but is not limited to:
- The name of the OHC provider (COB Carrier Name on the eligibility report).
- Contact or billing information.
120-day initial health appointment report
Health Net also generates the following report to help Medi-Cal providers keep track of members who need Department of Health Care Service (DHCS)-required examinations:
- 120-Day Initial Health Appointment Report - Lists members who have not had an initial health appointment (IHA) according to Health Net encounter data. Unlike eligibility reports, the 120-Day IHA report includes the number of days the member has been enrolled in Health Net's Medi-Cal plan and the member's age.
Additional information on eligibility report field descriptions is available as follows:
Health Net sends the Medi-Cal electronic eligibility file (277 byte format (PDF)) to capitated participating physician groups (PPG), capitated hospitals and some direct network physicians. It lists assigned members eligible for the reporting month, terminated members and members' eligibility effective dates with their affiliated primary care physicians (PCPs).
Terminated members appear on the report during the month of termination and the following month. Members who were assigned to and terminated from a PPG during the same month (due to events such as retroactive PCP change or inappropriate assignment) display the same date for the Effective Date and Termination Date fields.
The file also displays the member's Medi-Cal redetermination date for use in identifying members who are nearing the date of Department of Health Care Services (DHCS) redetermination of their eligibility for Medi-Cal benefits and may need to reapply.