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Provider Manual
Claims and Provider Reimbursement
Remittance Advice and Explanation of Payment System
Accessing Claims on the New Health Net Portal
Adjustments
Balance Billing
Billing Medicare/Medi-Cal Members Prohibited
Hold Harmless Provisions
Billing and Submission
Claims Submission
claims-submission-requirements-cmc-epo-hmo-medi-cal-ppo-
clinical-information-submission-medicare-cmc-epo-hmo-medi-cal-pp
CMS-1500 Billing Instructions
Hospital Acquired Conditions
Timely Claims Submission
Trauma Services
UB-04 Billing Instructions
Claims Receipt Acknowledgement
Claims Submission
Workers' Compensation
Capitated Claims Billing Information
1-_anesthesia-procedure-code-modifiers-with-the-minute-qualifier
Excessive Fees by Hospital-Based Providers
Eligibility and Capitation
Capitation Payments
Capitation Rates
Dual Risk
Electronic Capitation Reports
Hospital Liability Payment
PPG Liability Payments
Professional Stop Loss Levels
Reports
Capitation Rates
Reports
Eligibility Guarantee
Request for Payment Submission and Processing
Eligibility Guarantee Under COBRA
Fee-For-Service Billing and Submission
guid-8de55168-ce80-44fa-bb75-5e0aa4bb7b0b-en
FFS Claims Submission
Electronic Claims Submission
Electronic Claims Submission IFP
General Billing Guidelines
Institutionalized Members
Medicare Risk Adjustment Report
Payment for Service of Non-Participating Providers
Professional Claim Editing
Professional Stop Loss
Provider Participation Agreement
Refunds
Overpayment Procedures
Overpayment Procedures
Reimbursement
Endoscopies Classification Reimbursement
Emergency Claims
Reimbursement Amount
Reinsurance
Hospital Reinsurance
Shared Risk Reinsurance
Transfer Reinsurance
Special Risk Reinsurance
Schedule of Benefits
Shared Risk
Shared-Risk Reporting
Shared Risk Settlement
When Medicare is a Secondary Payer
Adjustments
Emergency Claims Processing
Insured Services
Premium Payment Grace Period for Beneficiary Qualifying for APTC
Professional Claim Editing
Timely Filing Criteria
Claims Coding Policies
Code Editing
Payment Integrity Policies
Compliance and Regulations
Mandatory Data Sharing Agreement
guid-36034170-ce79-4bc2-b770-211f4381cd4a-en
Provider Offshore Subcontracting Attestation
guid-ff87b58f-0c3d-4b43-bc82-372990761675-en
Communicable Diseases Reporting
Federal Lobbying Restrictions
Health Net Affiliates
Material Change Notification
Nondiscrimination
notice-nondiscrimination
guid-7d75d2c2-cc5a-4169-9894-c3aae7946ef1-en
Coordination of Benefits
COB Payment Calculations
guid-eff708e6-dbca-41ec-8298-2e532c48ec6b-en
guid-f827278b-cd7f-4a35-8a32-679d75caf20c-en
guid-b2d17aa1-0b66-4e92-9759-c4051b837348-en
The Plan's Right to Pay Others
When the Plan is the Primary Carrier
Disagreements with Other Insurers
guid-698da311-d230-4535-9c65-4ecb69c40eeb-en
guid-c8d014f2-1722-4b29-941e-53816b4ddfeb-en
guid-9b663d0d-12fd-4f03-8bdb-bb324ca58e5a-en
guid-4e3bf87c-d484-4727-9f33-42ebc03f3916-en
guid-a9a824cf-6d55-4cbc-8e9f-435161767d9c-en
Copayments
guid-756fa7a9-11df-4d5f-9e8f-82767844377f-en
guid-4ca0ee71-fe13-46cc-a90d-0e9f6f458eeb-en
guid-33276370-84ea-4195-9407-d315c2e83be9-en
guid-1229f8d7-0b79-407b-b460-20565a3d5670-en
Calculation of Coinsurance
guid-6dc604b5-4b5c-40f8-889a-c6069848941a-en
out-of-pocket-maximum
Verify Copayments
Credentialing
Application Process
Denial Notification
guid-e996bc43-bca7-4278-acb5-f2404fb77950-en
guid-3ba98f85-f21d-424d-9cae-a74cda674456-en
service-denial-templates--medicare
guid-3db642dc-9ca8-46eb-8abd-4ccfc935ac78-en
notice-of-medicare-non-coverage-and-detailed-explanation-of-non-0
guid-0798eb80-89ef-4e5f-a51b-5e25a7920fa6-en
guid-2d60d2e5-004d-467b-8fed-cb3375291ee7-en
requirements-for-notification-of-utilization-management-decision
guid-ac3720eb-227e-46c8-bae4-47c1c36223e0-en
guid-1b78faef-5699-4085-8678-c0727c7ffb9a-en
Service Denial Templates
member-denial-letter-templates-hmo-epo-ppo
required-elements-for-member-notification-letters--ppo11
Requirements for Notification of Utilization Management Decisions
Appeals, Grievances and Disputes
Expedited Reviews
member-appeal-overview-medicare-
expedited-organization-determination-rules-medicare
expedited-organization-determination-criteria-and-process-medica
Member Appeals
guid-563fe6cd-0c61-4bfd-87f4-fcd0f048bc19-en
guid-2e245022-bc7f-4123-8275-0adcf4533a7c-en
guid-0bfa86f6-048f-4a81-bb51-7df39bb8e05d-en
guid-bd3df487-fb44-4a09-b60a-d3eeafdf10cd-en
guid-066470bd-f3fc-427f-88e0-b654388b1d26-en
guid-7061b6a1-0590-4fda-bf42-683b7ccfb64d-en
guid-0e07a721-85ca-41b7-8f9b-d90d23cc84d6-en
Provider Appeals and Dispute Resolution
guid-adac62b5-3a8c-490d-a520-2acd9d3231d6-en
guid-19c6f94d-5ba5-4794-bb59-bfa44dae90fa-en
Acknowledgement and Resolution
Dispute Submission
Inquiry Submission
guid-2b732a9c-a768-485c-b900-08cdfb572ae4-en
Grievances
Eligibility
COBRA Continuation
guid-290d180e-66a8-463d-b491-2d32aeca83ac-en
Steps to Determine Eligibility
guid-dd0f8e79-ecf3-4609-a242-5b4152a3dc2f-en
guid-52db2d86-6989-40ea-aac9-decfa3d6b01a-en
guid-b82067a7-c247-4a0f-875b-e6637c975c01-en
guid-fec4c36b-0ea4-41cf-8393-3aa4f80c156d-en
guid-6a86564a-b9b8-48b2-a412-8c6946e0e5ba-en
Eligibility Verification Methods
guid-6d0585e7-92af-4e17-a414-fc9c3e440ec1-en
guid-db0a306a-ccd4-4c28-9fb9-6c174f198ce0-en
guid-c40af1f8-5d02-455e-b644-729eca33210f-en
Extension of Benefits
provider-responsibility-for-verifying-eligibility-for-ifp-member
guid-739d7e8a-a580-48ad-bff9-a751fc4e3817-en
Eligibility Reports
guid-961f2f26-6eb2-4155-9056-d97b9d9737a5-en
guid-cc2d185d-cf36-4183-9b8c-0fe941454856-en
guid-c4f25722-5790-46e9-8b56-06efd665ae38-en
guid-ea01a0e3-a708-4430-876a-5288b0de63fb-en
Emergency Services
guid-a7e212fa-f551-474c-ac03-7f7f23f20fd8-en
guid-1efb7954-9c37-41dc-9b2f-bfe8382f8b6b-en
guid-2860bde0-3615-4911-9cda-60531d70af5f-en
PPG Responsibilities
guid-183d7585-e315-4e3a-993e-42ebfe68e341-en
guid-b9a83280-3022-488e-9d3d-1ec7faf741f5-en
guid-04a7d664-6941-4372-9d15-5c5e09d46ded-en
guid-f4a0696d-f484-44fc-a2c9-d6d40a8b29d2-en
guid-9347e992-b339-4af5-851e-ae3ff9d27e42-en
guid-b11b990d-fa6f-4e83-8029-d4e2d84a7d06-en
Encounters
guid-2a6d6daa-c2e6-4098-986c-eb9cbec6b119-en
guid-b1dffe1a-4912-497a-ad42-a29ec657e559-en
guid-6fca88ef-748c-4e15-b5d5-ab9d9ad79b11-en
Lien Recoveries
guid-42b35881-cf72-4684-90bc-be491577ec0c-en
guid-11fe62de-0d5f-4ea4-830c-c14ccee01e90-en
Enrollment
annual-election-and-enrollment-periods-medicare
guid-a171030d-07ae-46fd-ae23-a77f8f718d5a-en
guid-7c3f8e27-ee7a-42b4-96c2-7a0677b363a8-en
Subscriber and Member Identification Numbers
Use of Social Security Numbers
administration-of-new-member-procedure
Conditions for Transfer Between PPGs
guid-1a22f346-7dd6-4176-b0d4-28ac558bd94a-en
guid-61eca107-3c74-4412-b23a-7710296c4f97-en
guid-4e4adce9-5ac2-4ce8-8b67-7d74569bc765-en
Member Terminations
guid-0b14b739-4953-4299-afdc-a5d6edaa9ba6-en
guid-ea3b7be3-12e6-45b6-9050-784f6509300e-en
Dependent Documentation Provided to Non-Subscriber
Late Enrollment Rules Waived
ID Cards
guid-2a380e03-b171-4f72-9906-4e702a4e1722-en
guid-e8defb12-9722-4496-8f0d-543b22d12923-en
Medical Records
guid-ceb83fb0-ae79-4d83-bd82-0926e2d16540-en
Confidentiality of Medical Records
Medical Record Documentation
guid-236f1421-db30-4af9-96c5-f64ab16fc89a-en
Medical Record Documentation Standards
Medical Record Performance Measurements
Member Rights and Responsibilities
guid-44040925-2914-4836-bf4c-dc7049578e73-en
guid-8a9f463d-5a9d-4a2f-a4c9-62653e3cfd71-en
Advance Directives
provider-responsibilities-and-procedures
member-rights-and-responsibilities
Prescription Drug Program
guid-27e5f34f-567a-49a7-b87b-d2e8239dd737-en
guid-9b08a35e-6757-45bd-9482-fea0122cfd7d-en
guid-d77d7f7d-ce53-43b6-ad8a-f9b62c489980-en
guid-eb644398-c89e-402e-9523-c3f9fbc44671-en
Generic Medications
guid-de08b85b-8e8e-408f-a2dc-876333cf01a1-en
Participating Pharmacy
guid-b9ebadb3-e55a-484c-997d-1e39ffa17200-en
Exclusions and Limitations
Compounded Medications
Diabetic Supplies
Off-Label Medication Use
Physician Self-Treatment
Prescription Mail-Order Program
Prior Authorization Process
Quantity of Medication to Be Prescribed
Recommended Drug List and Cal MediConnect Formulary
Prior Authorizations
guid-d84ceb7d-d438-442f-95cb-e359805ce8f8-en
guid-b25d6c50-2204-43c0-868e-f2b9628fa101-en
How to Secure Prior Authorization on the Provider Portal
guid-cbb45955-5ca6-437d-9221-8127c687a52c-en
guid-045f177e-f7be-4c32-86f8-a1a907bf3286-en
guid-8bc76b6b-82c9-455a-b131-221d4f70f1b3-en
guid-18a1e197-5d6c-445c-a630-d25d527baaf1-en
guid-41142752-6bb9-46c9-8828-6d7a741bbcf1-en
NIA - Prior Authorization
Product Descriptions
guid-bf45abbb-2752-4aae-97dc-cd8005e336ae-en
guid-f42f73bf-703f-4759-81d6-2f66a96ed9ca-en
guid-c8f575ee-15c3-4921-8cdf-930f3bfd9b53-en
Point of Service (POS) Product
guid-3085728a-6d56-45e4-a6a7-9edd488fbecc-en
Elect Open Access Two Tier Plan
Elect Open Access Tier 1 (HMO) Benefit Level
Elect Open Access Tier 2 (PPO Limited Benefit) Plan
Elect Two Tier Plan
Elect Tier 1 (HMO) Benefit Level
Elect Tier 2 (PPO In-Network) Benefit Level
guid-08478feb-d91c-4fe7-b766-8edac97e4cd8-en
guid-dcb5f96b-c56d-4180-bd70-9dada3ee41f5-en
guid-2ea24d07-5dff-470c-adcc-c80cc7c1768a-en
Leased PPO Benefit Program
Select Three Tier Plan
Select Tier 2 (PPO In-Network) Benefit Level
Select Tier 3 (Indemnity Out-of-Network) Benefit Level
Select Two Tier Plan
Select Tier 1 (HMO) Benefit Level
Select Tier 2 (PPO/Indemnity Out-of-Network) Benefit Level
Provider Oversight
Overview
Calendar of Required PPG Submissions
Corrective Action Plan
Fraud, Waste and Abuse
Member Appeals and Grievances
monitoring-provider-exclusions-medicare
Special Needs Plan Model of Care
Subdelegated Functions
Contractual Financial and Administrative Requirements
Contracts with Ancillary Providers
Discrimination against Health Care Professional Prohibited
guid-897e68dd-d985-4d9a-8f46-4222f66697c0-en
guid-3bcabd8b-e64c-4d8f-b31d-3cdd427098bd-en
guid-d3b569e8-498f-4235-93f3-1fadafd31d7b-en
guid-99192eca-c9d2-4898-aad5-398f08ee1609-en
guid-6bf5ffdc-dcc9-4bdf-90d4-efecc976a09e-en
Use of Performance Data
Delegated Medical Management
guid-77847193-b1d0-4c29-9f74-594f23676bba-en
guid-5ac015d4-d9f3-446d-8ce1-954cd0595035-en
guid-ef8258b3-5016-4a55-9046-affa8b061d38-en
guid-4c78fa12-3591-4ae1-adbe-03ddc44e487c-en
guid-d72f6375-42e2-4120-a8ca-82141f74d065-en
Facility and Physician Additions, Changes and Deletions
guid-37911c81-4c6c-47fe-8eef-a6ba4c145578-en
guid-9e228d27-dcec-4b5b-9508-62fadc9c5679-en
guid-b8d2bccf-5134-40eb-894c-c0013b280bae-en
guid-493caa6e-3009-45a7-8a83-f0e79f3ea14c-en
guid-7740cec2-2f5e-4f5e-a4fc-5d650c4d59ec-en
guid-4b4dbc7d-f23d-4b26-82d6-0b942cebb46c-en
guid-9c57649b-255f-410c-babb-80565465247e-en
Provider Outreach Requirements
Overview
guid-f5fdf6c1-9320-44ac-83bb-70c19f47ad3b-en
PPG and Hospital Termination
Service and Quality Requirements
guid-fbd5cc38-c1b3-42fa-a8cc-58e014cad264-en
guid-66532ebb-ee59-4b41-8bb7-42dbad32ab17-en
guid-09a00942-6e8c-4840-906a-a6fa9f55d3c4-en
guid-1ef0944a-bcb6-423a-9886-3c2600bc72fb-en
guid-d3ae9792-27a0-46c0-a34d-573df11ea0dc-en
Authorization and Referral Timelines
Credentialing and Recredentialing
guid-be02b430-b9e9-4ff5-9572-5e0b177ae6f4-en
guid-ca61120f-b349-46f3-a5fe-5b3c1a898690-en
guid-04ea8ee0-976f-4778-96d7-15f1c110636c-en
Threshold Languages and Language Assistance Codes
guid-39be06a4-9bf9-4d43-bf65-ba8bb47e69a8-en
Obtaining Interpreter Services
Member Appeals and Grievances
Monitoring Provider Sanctions for the Federal Employees Health Benefit Program
Quality Improvement
Disease Management Programs
Decision Power Disclaimer
decision-power-program-cmc-epo-hmo-ppo
Decision Power Program
Health Education Program
Smoking Cessation Program
Baby Care Basics Protocol
Early Prenatal Education Program Protocol
Health Management Programs
Overview
Behavioral Health Services
Breast Cancer Health Initiative
Decision Power Program
Senior Health Promotion Survey
Language Assistance Program and Cultural Competency
language-assistance-program-and-cultural-competency-medicare-11
language-assistance-program-and-cultural-competency-medicare-111
Quality Improvement Program
Overview
health-net-quality-improvement-committees-
guid-bf583e85-bdb9-466d-98fe-1001cadfc7cb-en
Quality Improvement HAC Program
Quality Improvement Program
Quality Improvement Program and Compliance and HEDIS
Quality of Care Issues
guid-6a001725-cd43-4f12-b6c2-393f848b08bd-en
Participation in Public Reporting of Hospital Performance
recognition-for-quality-performance-enhancedcare-ppo--ppo
Third-Party Liability
Coverage Explanation
Provider Responsibilities
Utilization Management
Overview
Affirmative Statement About Incentives
Availability of Criteria
Care Management
Overview
guid-fb726eb0-5535-4b43-8fa7-c6d9c0b892c2-en
guid-00ddda93-4f26-4988-a4cb-f22e0915c2e6-en
guid-1201f70f-d6a3-41fe-8630-5b50cf386ede-en
guid-3928ae2c-6ada-4981-bca7-fd63e2e7bfeb-en
Care Manager
NICU Levels of Care Criteria
Clinical Criteria for Medical Management Decision Making
Continuity of Care
Coverage Determination
Health Risk Assessment
Medical Data Management Reporting
Medical Data Management System
Medicare Certified Facilities
non-delegated-medical-management-medicare-epo-hmo-ppo
Notification of Hospital Admissions
Notification of Hospital Discharge Appeal Rights
Out-of-Area Services
Separation of Medical Decisions and Financial Concerns
Termination of Provider Services
Utilization Management Goal
Utilization Management Program Components
Concurrent and Retrospective Review
Continuity of Care
Economic Profiling
Hospital and Inpatient Facility Discharge Planning
Notification of Hospital Admissions
Adverse Childhood Experiences (ACEs)
guid-09368041-c058-4bb6-afcb-ac0fd8149c0e-en
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Last Updated: 10/08/2024
