21-573m Reminder about Balance Billing Members for Covered Services
Date: 08/06/21
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Members are only responsible for applicable copayments, coinsurance and deductibles
Balance billing is strictly prohibited by state and federal law and Health Net's Provider Participation Agreement (PPA). Participating physician groups (PPGs) are also responsible for ensuring participating providers follow these guidelines.
What is balance billing
This is when a participating provider bills a member for fees and surcharges –
- Above and beyond a member's copayment and coinsurance responsibilities for services covered under their benefit program, or
- For claims for services denied by Health Net or the affiliated PPG.
Collection action for non-payment
Participating providers cannot initiate or threaten to initiate a collection action against a member for non-payment of a claim for covered services. Participating providers agree to accept Health Net's fee for these services as payment in full, except for applicable copayments, coinsurance, or deductibles.
Note: This does not include pursuing collection of applicable coinsurance, deductibles, or copayments as specified in the member’s Evidence of Coverage, Certificate of Insurance or Member Handbook.
For Cal MediConnect plan (Medicare-Medicaid Plan) – Members are not subject to copayments, so providers must not charge coinsurance, copayments, deductibles, financial penalties, or any other amount.
Exception for non-covered services
Participating providers may bill a member for non-covered services when the member is notified in advance that the services to be provided are not covered and the member agrees in writing to receive the services.
Health Net will contact participating providers who exhibit a pattern and practice of balance billing members. These providers are subject to disciplinary action.
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 | ||
EnhancedCare PPO (SBG) | 1-844-463-8188 | provider_services@healthnet.com | |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider_services@healthnet.com | |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | provider_services@healthnet.com | |
Medicare (individual) | 1-800-929-9224 | provider_services@healthnet.com | |
Medicare (employer group) | 1-800-929-9224 | provider_services@healthnet.com | |
Medi-Cal | 1-800-675-6110 | N/A | |
| Cal Mediconnect – Los Angeles County | 1-855-464-3571 | N/A | provider_services@healthnet.com |
| Cal Mediconnect – San Diego County | 1-855-464-3572 | N/A | provider_services@healthnet.com |