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21-545 Support More Medi-Cal Members as Direct Network Launches in San Joaquin County

Date: 07/27/21

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to San Joaquin county.

Fee-for-service direct network begins October 1, 2021

Providers receiving this update are participating in the Health Net Medi-Cal network based on the terms of their current Health Net direct fee-for-service (FFS) Provider Participation Agreement (PPA). Health Net will add directly contracting participating providers, in addition to existing providers affiliated with participating physician groups (PPGs), to provide service to Medi-Cal members in San Joaquin County, as of October 1, 2021.

How this affects members

The Health Net Medi-Cal plan is available to residents in San Joaquin County. Health Net assigns a primary care physician (PCP) to members who enroll in Medi-Cal. These members obtain professional, institutional and ancillary services through Health Net’s direct network of participating providers.

Health Net Medi-Cal members may select and be assigned to a directly contracting PCP for primary care services. The member ID card will reflect the PCP’s name or clinic, and list “Direct Network” or clinic as the PPG.

How this affects you

Please note that this does not affect your current capitated Health Net membership through medical groups or PPGs. With this change, membership is available to you through capitation and direct network.

Refer to the following list for help with common administrative processes.

Medical management and prior authorization requests

Health Net is responsible for medical management of direct network Medi-Cal members. Providers are required to adhere to Health Net’s prior authorization requirements and request prior authorization from Health Net.

Claims submission

Submit claims directly to Health Net for Medi-Cal members who are assigned to a direct network PCP and/or clinics in San Joaquin County. Claims payment is in accordance with the terms and conditions of the Health Net direct FFS Medi-Cal PPA. Health Net encourages providers to submit claims electronically via their clearinghouse or through Health Net’s secure provider portal.

Providers may submit paper claims to Health Net at the address below on the standard CMS-1500 form using correct coding to ensure prompt, accurate claims processing.

Health Net Medi-Cal Claims

PO Box 9020

Farmington, MO 63640-9020

To check the status of claims that have been submitted, log in to the Health Net provider website.

Benefit coverage and referrals

Covered health care services and referrals for Health Net Medi-Cal members must be provided by, or referred to, participating Medi-Cal physicians, hospitals and ancillary providers. Specialist visits, including consultations, require a referral from the member's PCP, with the exception of OB/GYN services.

To find a participating Medi-Cal provider, refer to the Health Net provider website at provider.healthnet.com. Providers can search for specific provider types, including physicians, hospitals and ancillary providers, by geographic area, and filter results according to a member’s health plan.

Prior to referring a member for services, providers should validate the participation status of the rendering provider through the Health Net provider website or by contacting the Health Net Provider Services Center.

Direct network hospitals

Below is a list of hospitals available to direct network Medi-Cal members in San Joaquin County.

  • San Joaquin General Hospital – French Camp
  • St. Joseph’s Medical Center – Stockton
  • Dameron Hospital – Stockton
  • Doctors Hospital of Manteca – Manteca
  • Sutter Tracy Community Hospital – Tracy
  • Adventist Health Lodi Memorial Hospital – Lodi

Always check eligibility

Providers must verify member eligibility prior to each member appointment. You can check eligibility with the:

  • Health Net provider website.
  • Health Net Provider Services Center, as listed on the member’s Health Net ID card.
  • Health Net interactive voice response (IVR) system (available 24 hours a day, seven days a week), accessible through the Provider Services Center, as listed on the member’s Health Net ID card.

ID card components

You can identify Health Net Medi-Cal members through the information and product listed on their Health Net ID cards.  

  • Name – Name of member.
  • CIN – State-assigned Client Index Number (CIN).
  • PPG name – Name and phone number of the PPG to which the member is assigned, if applicable. For members assigned to a directly contracting PCP for primary care services, the PPG name will reflect “Direct Network”.
  • PCP information – Name, address and phone number of the member’s assigned PCP or federally qualified health center (FQHC)/rural health clinic (RHC), if applicable.
  • Effective date with PCP – Date the member was assigned to the PCP or FQHC/RHC, if applicable.
  • Pharmacy information – Contact and claims information for prescription medication processing vendor.
  • Issue date – Date the ID card was issued.
  • Enrollment date – Date the member was enrolled with Health Net Medi-Cal.
  • Copayment – Out-of-pocket expense the member is required to pay for covered services (varies by plan).
  • Important phone numbers – Health Net contact numbers.

Questions?

Providers may refer to the Health Net provider website or contact the Provider Services Center at the phone number on the member’s Health Net ID card for help with any of the following information:

  • Member eligibility and effective date.
  • Provider participation in Medi-Cal for member referrals.
  • Claims status.
  • Instructions on how to submit disputes and appeals.
  • Instructions on how to submit a complaint regarding the provision of care by a provider or express concerns about provider office staff.
  • Instructions on how to request the removal of members for disciplinary actions.
  • Instructions about the provider portal.

Additional information

Providers are encouraged to access the provider portal 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 800-675-6110.



Last Updated: 07/27/2021