PPO Coinsurance and Copayments

The coinsurance amount due from the member is based on the contract rate or the provider's usual charge, whichever is less. Health Net's payment plus the member's copayment or coinsurance amount equals 100 percent of the payment due to the provider pursuant to the participating provider's Provider Participation Agreement (PPA ).

Direct Payment to Providers

PPO participating providers submit claims to Health Net directly rather than billing the member. Health Net reimburses the provider directly, resulting in faster payment.

If the provider bills the member first rather than Health Net, the provider's agreement with Health Net may be subject to termination. If the provider does not comply with the claims submission guidelines and bills the member, Health Net reimburses the member (minus any scheduled copayments or coinsurance).

Explanation of Benefits

An explanation of benefit (EOB) detailing the provider reimbursement payment is mailed to both the provider and member on payment of the claim. The EOB displays amounts that were paid under the PPO benefit level, as well as member copayments and coinsurance amounts. It identifies charges which are over the contract rates for which the member is not to be billed.

If coverage is denied, the denial reason and appeal process is included in the member EOB and the provider remittance advice (RA).

Reimbursement Amount

When a member receives covered services from a participating provider, the member is not financially responsible for any expenses except copayments, coinsurance, or deductibles.

The provider may not charge the member for medical services that Health Net has denied as not covered under the member's benefit plan, unless the member has agreed in writing to be responsible for payment of such charges.