Professional stop loss limits the PPG's liability for providing capitation services rendered by participating providers to Health Net members. The PPG's liability for capitation services provided to a Health Net member in a calendar year for a standard contract is limited to the amount specified in the PPA. PPGs must select a professional stop loss level that is acceptable to Health Net and inform Health Net of its selection 60 calendar days prior to the beginning of the calendar year the stop loss level becomes effective. The cost of professional stop loss is deducted from the PPG's monthly capitation; however, if permitted under the PPG's PPA, the PPG may elect to purchase stop loss from a third party. If a PPG elects to purchase stop loss from a third party, it must provide Health Net with proof of stop loss acceptable to Health Net in accordance with the PPA. Self-insurance or stated reserves for Incurred But Not Reported (IBNR) is not stop loss.

When the PPG has made payments exceeding the applicable professional stop loss level and has purchased professional stop loss from Health Net, the PPG must complete and submit a Health Net PPG Professional Claim form (PDF) to Health Net.

The allowable payment for claims of treating providers under the stop loss program is based on terms set forth in the PPA. If, after Health Net's calculation, the PPG finds that its costs for capitated services provided to a member have exceeded the stop loss threshold, the PPG may make a request for payment under the stop loss program.

Professional stop loss is calculated and paid on a calendar year basis. The PPG notifies the