Claims Payment Requirements
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
Timeliness of payment of claims is monitored via the participating physician group's (PPG's) and capitated hospital's monthly claims timeliness report and is verified by routine and targeted audits conducted by the Health Net Delegation Oversight staff.
Claims Payment
Claims must reimbursed fully or partially within 30 calendar days of receipt. If a claim is incomplete, the physician or other provider must be notified as soon as possible, and no later than 30 calendar days after receiving the claim.
Interest and Penalty Payments for Late Claims
For claims received prior to January 1, 2026, PPGs and capitated hospitals are required to:
- Pay 90 percent of Medi-Cal clean claims within 30 calendar days of receipt.
- Pay 99 percent of Medi-Cal clean claims within 90 calendar days of receipt.
- Process 95 percent of all claims within 45 business days of receipt.
- Pay 15 percent interest or $15 per annum, whichever is greater, on late paid claims for emergency services rendered in the United States.
- Pay 15 percent interest on late paid claims for all other claims.
- Pay an additional $10 if the interest is not automatically included in the claim payment.
For claims received after January 1, 2026,
- Late paid claims must include interest at the rate of 15% per annum beginning with the first calendar day after the 30-calendar day period.
- Failure to automatically include all interest that has accrued on a late payment of a claim requires a penalty payment to the claimant the greater of either an additional $15 or 10% of the accrued interest on the claim.
Member notices about incomplete claims
PPGs and capitated hospitals must notify the member and provider in writing within 30 calendar days from receipt of the claim of an incomplete claim. Notices must specify:
- Date of denial notice.
- Member name.
- Provider name.
- Specific service.
- Date of service.
- Denied amount.
- Member responsibility amount.
- Reason for the denial - Claim denials for members must include a claim denial message.
- Provider and member appeals process and information, including plan name, address and telephone number for appeals.
Timely Claims Processing Requirements
When a member seeks medical attention from a provider, it is important that the provider attempts to determine eligibility with Health Net and enrollment in the PPG before providing care. If the provider or PPG does not follow the required steps for verification of eligibility and enrollment, Health Net does not accept financial responsibility for any services performed.
All Medi-Cal claims must be processed in accordance with these requirements:
- Process 95 percent of Medi-Cal clean claims within 30 calendar days of receipt.
- The payer is required to notify the provider in writing of contested claims.
- The payer is required to notify the provider in writing of contested claims within 30 calendar days.
PPGs and Hospitals are asked to produce an action plan if the volume of claims not processed within 30 calendar days without satisfactory notification to the provider is not in compliance with Health Net's standards. PPGs and Hospitals may be sanctioned if continued non-compliance is demonstrated. Sanctions can include freezing new enrollment and can ultimately result in termination of the provider's contract.
Health Net is required to submit encounter information to the Department of Health Care Services (DHCS) within 90 days following the month in which the service was provided. To meet this requirement, providers need to submit this information to Health Net within 60 days of the date of service. This allows Health Net 30 days to process the information prior to submission to DHCS.
Claims must be submitted within six months of the last date of the month during which services were rendered. Health Net denies claims submitted beyond this period.
If providers accidentally bill Electronic Data System (EDS), EDS denies the claim and sends the claim back to the provider with a notice instructing the provider to bill the correct carrier. EDS does not forward the claim to Health Net. It is the provider's responsibility to bill the correct payer.
Claims Universe Report
PPGs are required to report all family planning and sensitive service claims that were paid or denied to non-participating providers during the regular scheduled claims audit. To ensure Health Net PPGs comply with this requirement, PPGs must submit a Claims Universe Report for the month and include:
- Member name
- Member identification (ID) number
- Provider name
- Check date
- Check mail date
- Check number and amount paid
- Claim number
- Date of service
- CPT and ICD-10 codes
- Service(s) billed amount
- Place of service
- Signed informed consent form (if required for specific service)