25-545 New Claims Prepayment Review Policy Will Confirm if Documentation Supports Billed Charges
Date: 06/05/25
Send medical record documentation, if requested, for claims review policy
Effective August 12, 2025, Health Net will begin performing additional prepayment claim reviews for Marketplace HMO/PPO products using Optum’s Comprehensive Payment Integrity tool. As a result of these prepayment claim reviews, you may receive a request for medical records and billing documents that support the charges billed. Health Net is committed to continuously improving its overall payment integrity solutions to prevent overpayments due to waste or abuse.
Prepayment reviews may require medical records
Health Net uses widely acknowledged national guidelines for billing practices and supports the concept of uniform billing for all payers. These prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.
Physicians and other providers will receive detailed instructions about how to submit the requested documentation. Physicians and other providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.
If it is determined that a coding and/or payment adjustment is applicable, the physician or other provider will receive the appropriate claim adjudication. Physicians and other providers retain their right to dispute results of reviews.
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 chart below lists the policy number, policy name, a description of the policy, applicable types of providers and lines of business.
Policy number | Policy name | Description of policy | Providers | Lines of business |
|---|---|---|---|---|
CC.PP.074 | Optum Comprehensive Payment Integrity (CPI) | Optum CPI ensures that claims process and pay accurately. This may result in a claim denial with a request for medical records from the provider or supplier who submitted the claim to support the services submitted on the claim. After medical records are reviewed, the claim is processed to pay if the documentation supports the claim as billed. | Physicians, participating physician groups, hospitals, ancillary providers and behavioral health providers | Marketplace HMO and Marketplace PPO (Medicare effective as of July 1, 2023) |
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal. Behavioral health providers can call 844-966-0298.
Provider Services
Line of business | Phone number |
|---|---|
Ambetter from Health Net IFP Ambetter PPO | |
Ambetter HMO |
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.