20-626 Submit Data by November 10, 2020, for Supplemental Payment
Date: 08/21/20
This information applies to Hospitals.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Step-by-step instructions to help hospitals send in claims and encounters for payment programs
Health Net will be reviewing the files from the Department of Health Care Services (DHCS) to identify claims and encounters received for the State Fiscal Year (SFY) 2019-2020 Phase 1 service period of July 1, 2019, through December 31, 2019. Health Net will identify claims and encounters on file with Health Net but not on the DHCS file.
Health Net will create files that will include the paid/accepted claims and encounters “Not on DHCS” file with DHCS status codes as well as “Denied” with denial codes. The information will be available for participating hospitals via an Excel file for appropriate reconciliation.
Upcoming events that require your action
Hospitals can expect:
- Health Net will send an Excel file of claims and encounters via secure email with details on how to reconcile the claims and encounters. Health Net will update the reconciliation files as DHCS releases new files to us prior to the final submission date.
- Hospitals must submit any missing data or corrected information on the claims and encounters back to Health Net through the standard claims and encounters submission process, as well as submit the Excel file back by November 10, 2020.
- To ensure any claims paid by capitated provider groups that are not on the Health Net list are submitted to DHCS, it is recommended that the hospital reach out to the groups as soon as possible, so they can submit the encounters to Health Net by November 10, 2020.
Instructions for the encounter reconciliation file
Participating hospitals must submit any missing data or corrected information back to Health Net through the standard file processing submission method.
All claims and encounters submissions must be sent to Health Net through the standard claims and encounters submission process no later than November 10, 2020. Health Net cannot guarantee that any claims and encounters received after November 10, 2020 will make the final December 31, 2020 DHCS deadline.
1 Review the “DHCS” tab, “Not in DHCS” tab and “Denied” tabs.
A DHCS tab: all of the encounters already accepted by DHCS. No action needed.
B Not in DHCS tab: all of the claims/encounters that have been paid/accepted by Health Net and submitted to DHCS.
See “DHCS status” column for status of submission to DHCS.
- Accepted – DHCS has accepted the encounter. Should be on the next DHCS contract flagging release file.
- Rejected – DHCS has rejected the encounter. See “DHCS_Reason” for the reject reason and resubmit with correction prior to November 10, 2020.
- No status and Not Sent – is pending submission to DHCS. The Health Net team is working on submission, so no action is needed at this time.
C Denied tab: Review the claims for remediation if possible. Corrected claims and encounters must be resubmitted through normal claims processing guidelines for appeals.
2 Review the file against the hospital’s records of claims/encounter submissions for Health Net.
A Hospitals should identify any fee-for-service (FFS) claims not on the tabs and submit them to Health Net before November 10, 2020.
B Hospitals should identify any capitated encounters not on the tabs and reach out to the capitated entity to request submission to Health Net. To help support the submission of missing encounters, the hospital should send Health Net the list identifying the submitter/capitated group who made payment as soon as possible so Health Net can reach out to them to submit the encounter before November 10, 2020.
Help is available
For questions about these instructions, hospitals can contact:
Health Net contact for questions about claims and encounters | |
Dianna Bailey, Direct Pay Business Process Consultant | |
Health Net of California (HNCA) Direct Pay Team |
More help and information about this program
DHCS implemented the Designated Public Hospital (DPH) Enhanced Payment Program (EPP) and Private Hospital Direct Payment Program (PHDP).
DPH-EPP and PHDP provide supplemental reimbursement to participating hospitals based on the actual utilization of qualifying services for eligible members covered under managed care organizations (MCOs), as reflected in Medi-Cal claims and encounters reported to DHCS.
For additional information, visit DHCS at the following websites:
Additional information
Providers are encouraged to access the provider portal online for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 1-800-675-6110.