Request for Payment Submission and Processing
Participating physician groups (PPGs) must submit all eligibility guarantee payment requests with a completed PPG Professional Batch Form (PDF), and with a copy of the treating provider's original claim or invoice and proof of payment (such as the Explanation of Benefits (EOB) or Explanation of Payment (EOP) by the PPG to the Health Net Reinsurance Unit.
In addition, the PPG must:
- Write "Eligibility Guarantee" on the front of the PPG Professional Batch Form.
- If applicable, attach a copy of the substitute or replacement insurance plan's EOB or EOP (denying the claim) or copies of two billings sent to the member or person having legal responsibility for the member.
Indicate on all requests for payment from what source initial eligibility confirmation was obtained and the date obtained, as well as from what source and when ineligibility was confirmed. For example, "Eligibility Report dated March 2021, telephone verification February 23, 2021," or "Eligibility Certification Form signed by the member."
Eligibility Guarantee Processing
Eligibility guarantee requests for the calendar year must be submitted prior to February 28 of the following year. Health Net processes eligibility guarantee requests for payment on an ongoing basis and according to the terms of the eligibility guarantee in the PPG's Provider Participation Agreement (PPA).
Exclusions and Limitations
The following exclusions and limitations apply to eligibility guarantee:
- In order for Health Net to pay the PPG, the PPG must have contacted Health Net to verify eligibility for any member requiring emergency or inpatient hospital care.
- Members who come to the PPG for services without a valid Health Net identification (ID) card must sign an Eligibility Certification form. This form must also be signed if the member is not listed on the most recent Eligibility Report. PPGs should not call Health Net to verify eligibility for services provided within the PPG.
- PPGs do not receive eligibility guarantee payments for current members who transfer into the PPG.
- Health Net limits final eligibility guarantee payments to professional charges (capitated services and insured services).
- If any insured services are provided before the PPG is notified of the member's ineligibility, they are considered subject to eligibility guarantee requests for payment only if they have not been included in claims made to Health Net directly by treating providers through insured service liability.
- If a member is determined by Health Net to have been ineligible at the time of receiving hospital services (or other shared-risk benefits), Health Net is not responsible for payment. The member is liable for these charges.