Claims Submission

Provider Type

Participating Physician Groups (PPG)
Hospitals

The claim information listed below is required when submitting a professional stop loss, eligibility guarantee, or insured services claim. A copy of the original itemized bill or invoice must accompany the participating physician group (PPG) Professional Claim form. This information is required for the claim to be processed.

In accordance with the Provider Participation Agreement (PPA) Addendum, PPGs agree to pay claims promptly according to the Centers for Medicare & Medicaid Services (CMS) standards and comply with all payment provisions of state and federal law. CMS requires participating provider claims to be paid within 60 calendar days of receipt. PPGs also agree to include specific payment and incentive arrangements in agreements with all downstream providers.

Only one type of claim may be submitted per form.

Field Name	Required Information
Patient Name	The member's name as it appears on the Eligibility Report.
Subscriber ID Number	The subscriber ID number under which the member is covered.
Subscriber Name	The first and last name of the employee who is enrolled in Health Net as it appears on the Eligibility Report.
Member Code	An internal Health Net three-digit member code that identifies the member. This field may be left blank.
PPG Name	The name of the PPG in which the member is enrolled. This field may be left blank.
PPG #	The PPG's Health Net identification number.
Type of Claim	CMS-1500 or UB-04 (CMS-1450)
For Health Net Use Only	Do not write in the shaded columns. This space is used by Health Net to calculate eligible benefits. On computerized billing forms do not use the section titled "Insurance Company."
Date of Service	The date on which an individual service was provided to a member. Do not indicate one date and "10 visits."
RBRVS Code	The RBRVS and CPT/HCPCS code (billing codes). Do not use codes created for internal use by the PPG. These unique codes are not accepted by Health Net.
Description	English language description of the submitted RBRVS and CPT/HCPCS code. Do not use a PPG-substituted description.
Charges	The amount a fee-for-service member would be charged.
Doctor Number	Provider's tax identification number and National Provider Identifier (NPI) number.
Third Party	Any amounts collected by the PPG for COB (Medicare or other indemnity carriers). Claims should not be submitted until the other carriers are billed and a response is received.
Diagnosis	The ICD-10 code or the English language description of the illness or disease for which the patient is being treated.

Additional information may be required under certain circumstances.