Claims Payment Requirements

Accurate and timely processing and payment of claims is monitored via the participating physician group's (PPG's) monthly claims timeliness report and is verified by routine and targeted audits conducted by the Health Net Delegation Oversight staff.

PPGs are required to:

• Process 90 percent of Medi-Cal clean claims within 30 calendar days of receipt
• Process 95 percent of all Medi-Cal 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 and include an additional payment of $10 if the interest is not paid within five business days of the date of claim payment
• Issue payment within 10 business days for claims identified during an audit as underpaid or denied incorrectly

Timely Claims Processing Requirements

When a member seeks medical attention from a PPG, it is important that the PPG attempts to determine eligibility with Health Net and enrollment in the PPG before providing care. If the 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 90 percent of Medi-Cal clean claims within 30 calendar days of receipt
• Process 100 percent of all Medi-Cal claims within 45 business 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 45 days

Providers are asked to produce an action plan if the volume of encounters not processed within 30 calendar days without satisfactory notification to the provider is not in compliance with Health Net's standards. Providers 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 quarter being audited. The report may cover the same time period as the claims timeliness audit. The report should 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)