When the Plan is the Primary Carrier
- Participating Physician Groups (PPG)
(does not apply to HSP)
When the plan is the primary carrier, the participating provider is entitled to bill the other carrier as secondary after the provider has received the plan's adjudication decision.
A member is not entitled to an itemized statement reflecting the cash value of the services provided by the participating provider and covered by the plan (compliance with a request for itemization could enable a member to obtain unjust payment from an insurer or to document an itemized tax deduction far in excess of the actual cost).
A member is entitled to a statement documenting copayments made to the participating provider and charges for services not covered by the plan.
When Wellcare by Health Net is the primary payer and the member is enrolled in our exclusively aligned Dual Special Needs Plan (D-SNP), the secondary claim will be automatically forwarded to Health Net for payment on the Medi-Cal covered portion.
Refer to Claims Reimbusement and Balance Billing sections for more information.