Professional and Institutional Capitated Encounter Submission Requirements

Provider Type

  • Participating Physician Groups (PPG)
  • Ancillary
  • Ancillary
  • Hospitals

Providers may submit encounters to Health Net through an authorized electronic data interchange (EDI) clearinghouse, utilizing Snip level 1-5. To initiate or discuss the submission of encounter data files, contact the Capitated Claims/Encounter Department.

All professional and institutional encounters must be submitted in an electronic format. For additional information about how to submit encounters electronically, refer to 837 Institutional Transaction Standard Companion Guide (PDF), 837 Professional Standard Companion Guide (PDF) or 837 5010 Professional and Institutional Submissions Guidelines (PDF).

Capitated providers are contractually required to submit complete and correct data for all professional and institutional services performed. Before submitting encounter data, the submitter should contact the Health Net Encounter Department to discuss submission format and data requirements. Health Net currently accepts the ANSI 837 5010 X12 format.

All data should be submitted according to the terms of the Provider Participation Agreement (PPA). If the participating physician group (PPG) does not submit data within this time frame, the PPG is excluded from incentive programs