Skip to Main Content
HealthNet.com
Enter Keyword
Search
Provider Login
Line of Business
Medi-Cal
Medicare Advantage/D-SNP/C-SNP
HMO
PPO
Prison Health Care Provider Network
Provider Login
Line of Business
Medi-Cal
Medicare Advantage/D-SNP/C-SNP
HMO
PPO
Prison Health Care Provider Network
SEARCH
MENU
Go!
HealthNet.com
Medicare Advantage/D-SNP/C-SNP
D-SNP
Provider Manual
Appeals, Grievances and Disputes
Expedited Reviews
Member Appeals
Provider Appeals and Dispute Resolution
Grievances
Benefits
Overview
Acupuncture
AIDS
Alcohol and Drug Abuse
Allergy Treatment
Ambulance
Bariatric Surgery
Behavioral Health
Blood
Chemotherapy
Chiropractic
Clinical Trials
Complementary Supplemental Benefits
Cosmetic and Reconstructive Surgery
Dental Services
Dialysis
Durable Medical Equipment
Enteral Nutrition
Family Planning
General Benefit Exclusions and Limitations
Hearing
HIV Testing and Counseling
Home Health Care
Hospice Care
Hospital and Skilled Nursing
Immunizations
Initial Health Appointment
Injectables
Maternity
Medical Social Services
Nurse Midwife
Obesity
Outpatient Services
Physicians Visit
Podiatry
Post Stabilization
Preventive Services
Prosthesis
Rehabilitation Therapy
Respite Care
Routine Physical Exam
Second Opinion by a Physician
Support for Disabled Members
Surgery, Surgical Supplies, and Anesthesia
Transgender Services
Transplants
Transportation
Vision
X-Ray and Laboratory Services
TMJ
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing and Submission
Capitated Claims Billing Information
Eligibility and Capitation
Fee-For-Service Billing and Submission
Telehealth Billing Requirement
Institutionalized Members
Medicare Risk Adjustment Report
Payment for Service of Non-Participating Providers
Professional Claim Editing
Professional Stop Loss
Provider Participation Agreement
Refunds
Reimbursement
Reinsurance
Schedule of Benefits and Summary of Benefits
Shared Risk
When Medicare is a Secondary Payer
Claims Processing for DSNP in EAE Counties
Claims Coding Policies
Code Editing
Compliance and Regulations
Mandatory Data Sharing Agreement
Medicare Communications and Marketing Guidelines
Provider Offshore Subcontracting Attestation
Approval of Medicare Communications and Marketing Guidelines
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Reproductive Privacy Act
Coordination of Benefits
Overview
COB Payment Calculations
Determination of Primary Insurer
Medicare Plus (Plan J or HJA)
Recovery of Excessive Payments
The Plan's Right to Pay Others
When the Plan is the Secondary Carrier
Copayments
Collection of Copayments for Referrals
Collection of Medicare Copayments
Out-of-Pocket Maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
Claims Denial Requirements
Denial of Investigational or Experimental Treatment for a Terminal Illness
Service Denial Templates
Integrated Denial Notification - Notice of Denial Medical Coverage Template Information
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
Notification Delays
Requirements for Notification of Utilization Management Decisions
Disenrollment
Eligibility
COBRA Continuation
Dual-Eligible Medicare Beneficiaries
Steps to Determine Eligibility
Eligibility Reports
Eligibility Reports
Health Net Medicare Advantage Capitation Eligibility Summary Reports by Group and Provider
Health Net Medicare Advantage Reconciliation Report
Emergency Services
Coverage Explanation
Additional Monitoring Responsibilities
Instructions to Members Regarding Authorization
Out-of-Area Emergency or Urgently Needed Care
PPG Responsibilities
Encounters
Overview
Dual-Risk Contracts Encounter Data Submission
Error Notification
Lien Recoveries
Noncompliance with Encounter Data Submission
Professional and Institutional Capitated Encounter Submission Requirements
Enrollment
Annual Election and Enrollment Periods
Member Enrollment
Part D Enrollment
Subscriber and Member Identification Numbers
Use of Social Security Numbers
Administration of New Member Procedure
Conditions for Transfer Between PPGs
Member Terminations
ID Cards
Member ID Card
Medical Records
Confidentiality of Medical Records
Medical Record Forms and Aids
Medical Record Documentation
Member Rights and Responsibilities
Advance Directives
Member Rights and Responsibilities
Prescription Drug Program
Medicare Advantage Part B
Accessing Part D Prescription Medications
Compounded Medications
Coverage Explanation
Generic Medications
Medication Therapy Management Program
Participating Pharmacy
TransactRx
Prior Authorizations
Overview
Authorization for Admission to Hospital or SNF
Diagnostic Procedures
How to Secure Prior Authorization on the Provider Portal
PPGs' Responsibilities for Authorization
Prior Authorization Process for Direct Network Providers
Peer-to-Peer Review Requests
Product Descriptions
Medicare Select Plan Description
Medicare Plans
Optional Supplemental Benefits Package
Provider Oversight
Provider Oversight Overview
Calendar of Required PPG Submissions
Corrective Action Plan
Fraud, Waste and Abuse
Member Appeals and Grievances
Monitoring Provider Exclusions
Special Needs Plan Model of Care
Sub-Delegated Functions
Contractual Financial and Administrative Requirements
Delegated Medical Management
Facility and Physician Additions, Changes and Deletions
Service and Quality Requirements
Quality Improvement
Disease Management Programs
Health Management Programs
Language Assistance Program and Cultural Competency
Quality Improvement Program
Referrals
Overview
Direct Network Referral Process
Investigational and Experimental Treatment
OB/GYN Self-Referrals
Out-of-Network Referrals
Post-Stabilization Care
Role of the Primary Care Physician
Self-Referral Benefits
Third-Party Liability
Coverage Explanation
Urgent Care
Utilization Management
Overview
Affirmative Statement About Incentives
Availability of Criteria
Care Management
Clinical Criteria for Medical Management Decision Making
Continuity of Care
Coverage Determination
Health Risk Assessment
Medical Data Management Reporting
Medical Data Management System
Medicare Certified Facilities
Non-Delegated Medical Management
Notification of Hospital Admissions
Notification of Hospital Discharge Appeal Rights
Out-of-Area Services
Separation of Medical Decisions and Financial Concerns
Termination of Provider Services
Utilization Management Goal
Utilization Management Program Components
Behavioral Health Provider Operations Manual
Prior Authorization Requirements
Participating Physician Group (PPG) Performance Scorecard
Payment Policies
Provider Updates and Notices
Forms and References
Education, Training and Other Resources
Provider Pulse Newsletter
Contacts
Glossary
Quality Management Program and Resources
Provider Manual Archive
Health Equity, Cultural and Linguistic Resources
Medicare Advantage/D-SNP/C-SNP
Select provider library topic from left navigation bar.
Last Updated: 04/28/2025
