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Provider Responsibilities

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG) 
    (does not apply to HSP)
  • Hospitals
  • Ancillary

How to notify and respond to a TPL request

Providers must notify Health Net or the participating physician group (PPG) in writing of all potential and confirmed third-party liability (TPL) cases that involve a Health Net Medi-Cal member. If a provider has received subpoenas from attorneys, insurers, or members for copies of bills concerning a TPL case, the provider must notify Health Net with copies of the request and copies of documents released as a result of the request. The information must also include the name, address and telephone number of the requesting party. The notification must be submitted via email.

Note: In all third-party tort liability cases, providers must bill Health Net or the PPG as usual, and give all details regarding the injury or illness. Health Net pays usual benefits, and refers the case to DHCS to pursue the recovery.

Requests from Health Net for TPL

If the Department of Health Care Services (DHCS) requests information regarding an individual TPL case, Health Net will send providers a letter to request TPL claims information and an itemized list of services for affected members. Providers are responsible for supplying Health Net with copies of the requested documents in the time frame described in the letter in order for Health Net to deliver the information to DHCS no later than 30 calendar days of the DHCS request. Providers must submit the information to the Health Net Third-Party Liability Department.

Pursuant to DHCS All Plan Letter 21-007, the claims data must meet the standard reporting requirements set forth by DHCS. DHCS requires the use of a DHCS-approved Excel worksheet to submit and receive TPL claims data. All claims data submissions must include the following data elements in the approved Excel format below.

Note: An approved Excel worksheet will be provided by Health Net along with the request for TPL claims data. The PPG must follow the instructions in the TPL claims data request.

Field

Description

MCP/IPA

Name of the PPG or independent physician association (IPA) (the name of the business entity owned by a network of independent physicians)

Member name

The name of the Medi-Cal member

Date of birth

The Medi-Cal member's date of birth

CIN

The Client Index Number (CIN) 9-digit character on the Medi-Cal Benefits Identification Card. It starts with the number “9” and ends with an alpha (A-Z).

Date of injury

The Medi-Cal member's date of injury

CCN

A Claim Control Number (CCN) uniquely identifies any processed claims within a specific plan code.

Claim line number

The last two characters of the CCN are the claim line number and they are unique for each service.

Claim type

Identifies the general type of service that was rendered

Service from date

Identifies the start date of the service on a claim

Service to date

Identifies the end date of the service on a claim

Provider legal name

Indicates the provider's legal name

NPI

The National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare & Medicaid Services.

Diagnosis code 1

Identifies the diagnosis code for the principal condition requiring medical attention

Diagnosis code 2

Identifies the secondary diagnosis code which requires supplementary medical treatment

Drug label name

Label name of the drug (if claim is for drug)

Billed amount

Identifies amount billed to the plan from the provider

Paid amount

Identifies the actual amount paid to the provider for services

Reasonable value

Identifies the reasonable/customary value of the service provided. Absent the “Amount paid, due to capitated or other service type, the “Reasonable value” of the service must be provided, pursuant to Title 28, California Code of Regulations (CCR), section 1300.71(a)(3).

CPT code

Official CPT code used to report medical, surgical, and diagnostic procedures and services. CPT is a registered trademark of the American Medical Association.

CPT type

There are three types of CPT codes: Category 1 (procedures and contemporary medical practices), Category 2 (clinical laboratory services) and Category 3 (emerging technologies, services and procedures). CPT is a registered trademark of the American Medical Association.

Claim deny reason code 1 & description

Primary denial code and description (if claim denied)

Claim deny reason code 2 & description

Secondary denial code and description (if claim denied)

Last Updated: 07/21/2021