21-612 Understand Your Payment Reimbursement Process
Date: 08/30/21
This information applies to Tribal FQHC providers
For Medi-Cal, this information applies to San Diego county.
Make sure you are getting paid in full
Per All Plan Letter (APL) 21-008 distributed by the Department of Health Care Services, Health Net and its participating physician groups (PPGs) must apply an Alternate Payment Methodology (APM) to eligible medical, mental health and ambulatory services provided by their contracted Tribal Federally Qualified Health Centers (Tribal FQHC).
Contracted directly with a PPG?
Here is what you need to know:
1 PPGs are to pay you the Medi-Cal rate for up to three visits per day, in any of the following combinations:
- Medical
- Mental health
- Ambulatory
2 Then they must submit the encounter data to us so that we can pay you the difference in accordance with the APM.
Are you missing payments?
If you are missing payments from Health Net, contact your PPG directly to see if the PPG has submitted the encounter. Health Net is not able to pay the difference without the encounter data from your PPG.
Contracted with Health Net directly?
Here is what you need to know:
If you are directly contracted with Health Net your payments will be issued directly from Health Net.
1 You will receive the regular claims payment.
2 A subsequent payment that makes up the APM rate difference will be issued.
Are you missing payments from Health Net?
If you are missing payments from Health Net, contact Health Net at 800-675-6110.
What are the Tribal FQHC APM Rates?
Beneficiary | 2021 rates |
|---|---|
Dual Rate (Medi-Cal beneficiaries with full Medicare coverage or Medicare Part B only) | $371.49 |
Non-Dual Rate (Medi-Cal beneficiaries that do not have Medicare Coverage or have Medicare Part A only) | $519 |
Additional information
For questions regarding the information contained in this update, refer to APL 21-008 distributed by Department of Health Care Services on May 12, 2021.
For all other questions, contact the Health Net Medi-Cal Provider Services Center within 60 days at 800-675-6110.