25-348 Avoid Unnecessary Denials and Claims Processing Delays by Following These Payment Policies
Date: 04/22/25
Payment edits go into effect June 27, 2025, including new ambulance POS coding edits, and edits to support urodynamic testing and fundus photography medical policy
Refer to the information below this update to learn about new payment edits from Health Net. The policies will help you correctly bill for certain services. This information applies to physicians and other providers.
Access to payment policies
Access Health Net’s payment policies, listed by line of business or product, at Payment Policies.
Policies indicate acceptable billing practices
Health Net publishes payment policies to inform physicians and other providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. Health Net applies these policies as medical claims reimbursement edits within its claims adjudication system. This is in addition to all other reimbursement processes that the Plan currently employs.
Health Net believes that publishing this information will help physicians and other providers bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments.
The policies address:
- coding inaccuracies
- diagnosis-to-procedure code mismatch
- inappropriately modified procedures
- unbundling
- incidental procedures
- duplication of services
- health plan-specific payment rules for procedures and services
Policies are based on industry standards
The policies are based on medical literature and research, and industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare & Medicaid Services (CMS) and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by California or in regulations.
Note, actual CPT codes to be included or excluded in the payment policies are not all-inclusive and may be subject to change.
Payment policy chart
The following chart lists the policy number, policy name, a description of the policy, applicable provider types and applicable lines of business.
Number | Name | Description | Applicable provider(s) | Lines of business |
|---|---|---|---|---|
CC.PP.011 | Code Editing Overview | Ambulance place of service (POS) criteria will now be subject to a strict correct-coding edit. Claims billed under a non-ambulance POS with an Ambulance Procedure Number will be denied. Please take note of the following approved Ambulance POS codes:
Please ensure that claims are submitted with the correct Ambulance POS coding to avoid denials. | All provider types (physicians and other providers) | All lines of business; note, the only lines of business that will experience a change related to the edits described in this provider update will be non-marketplace Commercial and Medi-Cal |
CP.MP.98 | Urodynamic Testing | Urodynamic testing plays a vital role in the comprehensive evaluation of voiding dysfunction. Clinicians are expected to exercise clinical judgment in selecting the appropriate urodynamic tests based on an accurate evaluation and symptom characterization. The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies. Claims billed outside of the medical necessity requirements outlined in this policy will be denied. | All provider types (physicians and other providers) | All lines of business; note, the only lines of business that will experience a change related to the edits described in this provider update will be non-marketplace Commercial and Medi-Cal |
CP.VP.29 | Fundus Photography | Fundus photography involves using a retinal camera to capture images of the vitreous, retina, choroid and optic nerves. These images, which may be either photographic or digital, become part of the patient's permanent medical record. Typically, photographs are taken through a dilated pupil to ensure high-quality images, unless clinically contraindicated or unnecessary for proper image acquisition. This policy outlines the medical necessity guidelines for the use of fundus photography in patient care. Claims billed outside of the medical necessity requirements outlined in this policy will be denied. | All provider types (physicians and other providers) | All lines of business; note, the only lines of business that will experience a change related to the edits described in this provider update will be non-marketplace Commercial and Medi-Cal |
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center at:
Line of business | Phone number | |
|---|---|---|
IFP Ambetter PPO | ||
IFP Ambetter HMO | ||
Health Net Employer Group HMO, POS & PPO | ||
Medicare (Individual & Employer Group) | ||
Medi-Cal | N/A | |
Behavioral Health Providers | N/A |
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.