Eligibility Verification
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
When a patient seeks medical attention from a participating physician group (PPG), hospital or other provider, that provider must attempt to determine eligibility before providing care. If the provider verifies eligibility according to the steps outlined below, the provider is compensated even if the patient is later determined to be ineligible. If the provider does not verify eligibility, the Plan does not accept financial responsibility for any services performed on an ineligible patient.
Member eligibility is verified at the time that the identification (ID) card is issued; however, a member's possession of an ID card does not guarantee their eligibility. In cases where a member has lost an ID card or where eligibility may be in question, providers can verify eligibility as follows:
- Online: For step-by-step guidance on how to verify eligibility on the Health Net's provider portal, download the Save Time Navigating the Provider Portal (PDF),Save Time Navigating the Provider Portal – Community Health Plan of Imperial Valley (PDF) or Save Time Navigating the Provider Portal – CalViva (PDF) booklet.
Patient History provides specific member eligibility, copayments, claims status and other services. Providers may also search by dates of service to refine the search.
- Refer to the interactive voice response (IVR) system by phone, 24 hours a day, seven days a week and follow the prompts for Health Net Medi-Cal Provider Services Center, Community Health Plan of Imperial Valley Provider Services Center or CalViva Health Provider Services Center (for Fresno, Kings and Madera counties). Select the appropriate option to verify a member's eligibility, copayments, benefits, claims status, and more.
- Via Point of Service (POS) device, Affiliate Computer Services (ACS) or claims and eligibility real-time systems (CERTS) available through the Medi-Cal eligibility website at www.medi-cal.ca.gov:
- Providers who have access to EDS POS devices may swipe the member's Medi-Cal Beneficiary Identification Card (BIC) through the device to get information about the member's current eligibility status, health plan affiliation, and PCP name and phone number. Providers may also use ACS, an automated interactive voice response system, to verify eligibility, share of cost and other services using a touch-tone phone and PIN
- If further information is required about the member's PCP or PPG affiliation, providers may call the Eligibility Verification Line as listed on www.medi-cal.ca.gov
- CERTS is available online to verify eligibility for pharmacy providers
- Providers who have access to EDS POS devices may swipe the member's Medi-Cal Beneficiary Identification Card (BIC) through the device to get information about the member's current eligibility status, health plan affiliation, and PCP name and phone number. Providers may also use ACS, an automated interactive voice response system, to verify eligibility, share of cost and other services using a touch-tone phone and PIN
- Another option is available online through TransUnion® MedConnect website at www.meddatahealth.com/login.aspx for those providers who have an account. Providers may log in and enter the member's Plan ID number to get information about current eligibility, health plan affiliation and assigned primary care physician (PCP).
- Eligibility verification via the provider's clearinghouse. Health Net is a Phase I- and Phase II-certified entity with the Council for Affordable and Quality Healthcare (CAQH) Committee on Operating Rules (CORE) for eligibility responses. Providers contact their vendor/clearinghouse to submit transactions via this method using an EDI transaction or clearinghouse product.
For dual special needs plan (D-SNP) member eligibility information, refer to Dual-Eligible Medicare Beneficiaries.