Professional and Institutional Capitated Encounter Submission Requirements
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Providers are required to submit encounters to Health Net through an authorized electronic data interchange (EDI) clearinghouse, utilizing Snip level 1-5. To initiate or discuss the submission of encounter data files, contact the Capitated Claims/Encounter Department.
All professional and institutional encounters must be submitted in an electronic format. For additional information about how to submit encounters electronically, refer to 837 Institutional Transaction Standard Companion Guide (PDF), 837 Professional Standard Companion Guide (PDF) or 837 5010 Professional & Institutional Standards for Trading Partners (PDF).
Capitated providers are contractually required to submit complete and correct data for all professional and institutional services performed. Before submitting encounter data, the submitter should contact the Health Net Encounter Department to discuss submission format and data requirements. Health Net currently accepts the ANSI 837 5010 X12 format.
All data should be submitted according to the terms of the Provider Participation Agreement (PPA). If the participating physician group (PPG) does not submit data within this time frame, the PPG is excluded from incentive programs.
California Department of Health Care Services (DHCS) QMED 2.0 requirements
PPGs must:
- Submit and ensure acceptance of encounters within 90 days of the date of service.
- Ensure all encounter data is complete and accurate, including Type 1 (individual) rendering provider National Provider Identifier (NPI).
- Review denial reports and correct errors within 10 calendar days of the date of denial.
- Resubmit all Department of Health Care Services (DHCS) denied encounters within the reporting quarter.
- Prevent duplicate submissions by following established billing practices.
- Monitor performance reports and take immediate action to resolve identified issues.
Key requirements
1) Timeliness of submission:
- Effective October 1, 2026, to meet DHCS’s requirement that data be accepted within 120 days, the Plan requires at least 90% of encounters to be submitted and accepted within 90 days of the date of service (DOS).
- Effective October 1, 2026, to meet DHCS’s requirement that denied encounters be corrected within 15-calendar days, the Plan requires at least 97.5% of DHCS-denied encounters to be corrected within 10 calendar days of the denial.
2) Accuracy (Correction of DHCS denied encounters):
- At least 99.5% of DHCS denied encounters must be corrected within the reporting quarter.
3) Reasonability
- Total DHCS denied encounters must remain below 2%.
4) Completeness of data:
- At least 90% of encounter service lines must include a Type 1 (individual) rendering provider NPI.
- Ensure NPI matches National Plan and Provider Enumeration System (NPPES) Type 1 or Type 2 and is valid on DOS.
5) Uniqueness (duplicate submissions):
- Duplicate encounters must remain below 0.5%.
- Duplicate service lines must remain below 5% for Institutional encounters and 0.5% for Professional encounters.