Eligibility Verification Methods
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
When an individual seeks medical attention from a participating physician group (PPG), hospital or other provider, the provider must attempt to determine eligibility with Health Net before providing care.
Member eligibility is verified at the time that the identification (ID) card is issued; however, possession of the card does not guarantee eligibility. In cases where a member has lost an ID card or where eligibility may be in question, eligibility can be verified as follows:
- Eligibility Reports (applies to capitated PPGs and hospitals). Refer to Use Eligibility Report to Verify Member Information in the Monthly Eligibility Reports section for more information.
- Online download the Save Time Navigating the Provider Portal (PDF) booklet for step-by-step instructions.
- Eligibility verification via the provider's clearinghouse. Health Net is a Phase I- and Phase II-certified entity with the Council for Affordable and Quality Healthcare (CAQH) Committee on Operating Rules (CORE) for eligibility responses. Providers must contact their vendor/clearinghouse to submit transactions via this method using an EDI transaction or clearinghouse product.
Contact the Health Net Provider Services Center for questions about Medicare Advantage members.