Insured Services
Insured services are contracted services that are arranged or paid for by the participating physician group (PPG), and for which the PPG and Health Net have negotiated specific provisions in the PPG's Provider Participation Agreement (PPA) whereby Health Net has agreed to pay a negotiated amount to the PPG in each case where the contracted services are rendered to a member assigned to the PPG. Such payments are in addition to the capitation paid per member. The specific description, definition and terms of payment for each insured service are outlined in the PPG's PPA addendum. Unless otherwise provided in the applicable addendum to the PPG's PPA, the terms of the insured services are described below.
Types of Insured Services
Pre-Existing Pregnancy
In addition to monthly capitation, Health Net pays a standard, flat fee to the PPG for costs it incurs in paying treating providers for professional maternity care and delivery services provided to any Health Net member who selects or is assigned to the PPG and gives birth within six months after enrollment with Health Net.
The following information is required when submitting a request for payment:
- Health Net Professional Batch Form (PDF) with completed member information
- Copy of treating provider's delivery service claim (CMS-1500)
- Related hospital bill (UB-04) to document date of delivery, or copy of authorization
IVF/GIFT/ZIFT (Advanced Infertility Treatments)
Health Net pays the PPG for the costs it incurs in compensating treating or participating providers for prior-authorized and case-managed treatment provided by a fertility center approved by Health Net, provided that: (i) Health Net member is entitled to advanced infertility treatments as a covered benefit per the Evidence of Coverage (EOC), and (ii) Health Net member's PPG, primary care physician (PCP) and Health Net's case management agree that the advanced infertility treatments meet the medical criteria for coverage. Payment is in accordance with the applicable PPA addendum, subject to scheduled copayments for infertility treatment services. Refer to the Family Planning topic and the member's EOC for a detailed description of covered services, exclusions and limitations.
The following information is required when submitting a request for payment:
- Health Net PPG Professional Batch form (PDF) with completed member information
- Copies of all treating providers' claims (CMS-1500) relating to the advanced infertility treatments
- Proof of payment, to include the PPG contract amounts paid to treating providers for each service
Additional Insured Services
Additional services may be designated as Insured Services by an agreement between Health Net and PPG.
Requests for Payment Submission Requirements
The PPG must submit all requests for payment with a copy of the original CMS-1500 or UB-04 as applicable, from the treating provider, and with the completed Health Net PPG Professional Batch form. The requests for payment must be submitted to Health Net within 120 days from the date of service or as stated in the applicable PPA addendum. All requests for payment must be sent to the Health Net Reinsurance Unit.
Requests for Payment Processing
Payment for each pre-existing pregnancy is a specified flat fee. Payment for advanced infertility treatments is described in the applicable PPG PPA addendum.