PPG Liability Payments

In some instances, Health Net pays for services considered the participating physician group's (PPG's) liability, otherwise known as capitated services. PPG liability claims that Health Net pays on behalf of the PPG may be the result of the PPG accessing Health Net's contract rates with another provider or of a quality assurance review. PPG liability claims that Health Net pays on behalf of the PPG are deducted from the monthly professional services capitation.

Health Net strongly encourages all PPGs to establish contractual agreements with providers used by the PPG. Health Net accommodates the PPG's request to adjudicate and pay PPG liability claims to providers without a contractual agreement in place with the PPG as stated in the PPG's Provider Participation Agreement (PPA).

Health Net requires that the PPG respond to Health Net and provide the necessary documentation demonstrating that the claim has been resolved via fax or email within 10 calendar days of the PPG's receipt of Health Net's request for information. If the PPG does not provide an acceptable response to Health Net, Health Net may pay the claim on behalf of the PPG. Health Net may pay claims at the lesser of Health Net's contract rate with the provider, provider subcontract terms or provider's billed charges.

Each PPG receives a copy of the monthly PPG Liability Claims Paid by Health Net Report.