Provider Responsibility

Participating providers are responsible for:

• Providing health care services to members within the scope of the provider's practice and qualifications.
• Providing care that is consistent with generally accepted standards of practice prevailing in the provider's community and the health care profession.
• Accepting members as patients on the same basis that the provider accepts other patients (non-discrimination). For additional information, refer to the Nondiscrimination topic.
• When consistent with provision of appropriate quality of care, referring members only to participating providers in compliance with the plan's written policies and procedures.
• Obtaining current insurance information from the member.
• Cooperating with the plan in connection with health plan performance of utilization management and quality improvement activities, including prior authorization of necessary services and referrals.
• Informing the member that the referral services may not be covered by the plan when referring to non-participating providers.
• Providing the plan with medical record information if requested for a member for processing application for coverage; for prior authorizing services or processing claims for benefits; or for purposes of health care provider credentialing, quality assurance, utilization review, case management, peer review, and audit. (the plan has a valid signed authorization from our members authorizing any physician, health care provider, hospital, insurance or reinsurance company, the Medical Information Bureau, Inc. (MIB), or other insurance information exchange to release information to the plan if requested. Participating providers may obtain a copy of this authorization by contacting the plan. The plan does not reimburse for the cost of retrieval, copying and furnishing of medical records).
• Cooperating with any authorized plan business associate who may need to access member records that may include payment or medical records to determine the proper application of benefits, as well as the propriety of payments (including any claims payment recovery actions performed on behalf of Health Net).
• In the event of provider termination, cooperating with the plan and other participating providers to provide or arrange for continuity of care to members undergoing an active course of treatment, subject to the requirements and limitations of California statute.
• Operating and providing contracting services in compliance with all applicable local, state and federal laws, rules, regulations, and institutional and professional standards of care including federal laws and regulations designed to prevent or ameliorate fraud, waste, and abuse, including, but not limited to, applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. 3729 et. seq.), and the anti-kickback statute (section 1128B(b)) of the Act); and Health Insurance Portability and Accountability Act (HIPAA) administrative simplification rules at 45 CFR parts 160, 162, and 164.

Other provider rights and responsibilities are included in the Provider Participation Agreement (PPA).