21-575m 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 Fresno, Kings, and Madera counties.

Members are only responsible for applicable copayments, coinsurance and deductibles

Balance billing is strictly prohibited by state and federal law and CalViva Health's 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 CalViva Health 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 the health plan, or the affiliated PPG.

Collection action for non-payment

Participating providers cannot initiate or threaten to initiate a collection action against a CalViva Health member for non-payment of a claim for covered services. Participating providers agree to accept the health plan’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 benefits contract.

Exception for non-covered services

Participating providers may bill a CalViva Health 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. 

The health plan 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 CalViva Health at 888-893-1569.