Health Net Federal Services
Preferred Provider Network
Provider Manual
March 2015
Contents
Overview............................................................................. 3
Provider Tools...................................................................... 5
Address Change Or Other Practice Information........................................................................ 5
www.hnfs.com.............................................................................................................................. 5
Online Network Provider Directory.................................................................................... 6
Provider Updates.................................................................................................................. 6
Contact Information............................................................. 6
Contact Us..................................................................................................................................... 6
Important Provider Information........................................... 7
General Administrative Requirements........................................................................................ 7
Fraud, Waste And Abuse............................................................................................................... 7
Beneficiary Identification (ID) Card........................................................................................... 9
Covered Services........................................................................................................................... 9
Credentialing.............................................................................................................................. 10
Delegation................................................................................................................................... 12
Prior Authorization And Referral....................................... 14
Prior Authorization And Notification....................................................................................... 14
Referrals....................................................................................................................................... 14
Claims Procedures............................................................. 15
Claims Submission..................................................................................................................... 15
Claims Ajudication..................................................................................................................... 15
Claims Adjustment Procedures.................................................................................................. 16
Timely Filing Criteria................................................................................................................. 17
Reimbursement........................................................................................................................... 17
Office Procedures.............................................................. 19
Medical Records.......................................................................................................................... 19
Clinical Information Submission.............................................................................................. 20
Provider Inquries................................................................ 20
Grievances And Appeals/Disputes..................................... 21
Grievances................................................................................................................................... 21
Appeals/Disputes........................................................................................................................ 21
Contractual Disputes.................................................................................................................. 23
Health Care Management And Administration.................. 23
Utilization Management............................................................................................................ 23
Case Management....................................................................................................................... 23
Clinical Quality Management.................................................................................................... 24
Discharge Planning..................................................................................................................... 24
Policy on Separation of Medical Decisions and Financial Concerns....................................... 24
Rights And Responsibilities................................................ 25
Beneficiary Rights And Responsibilities.................................................................................... 25
Index.................................................................................. 27
Page 2 of 27
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Overview
About Preferred Provider Network: Health
Net Federal Services, LLC develops and
maintains preferred provider products
to serve multiple governmental program
populations through “PPO style” networks
of providers who agree to offer medical and
behavioral health services at competitive
reimbursement rates. Vital to our success,
MHN (Health Net’s behavioral health
company), develops and maintains the
behavioral health network. The Health
Net Preferred Provider Network (PPN) is
comprised of those hospitals, physicians,
physician organizations, other health care
providers, suppliers, and other organizations
that have met Health Net credentialing
and recredentialing requirements and are
participating through an executed Provider
Participation Agreement (PPA).
About Health Net Federal Services, LLC:
Health Net Federal Services, LLC is the
government operations division of Health
Net, Inc. Health Net Federal Services has a
25-year history with government and military
health care programs for the Departments of
Defense (DoD) and a 15-year history with the
Department of Veterans Affairs (VA). Health
Net Federal Services has supported and
managed federal contracts since 1988.
About Health Net, Inc.: Health Net, Inc. is a
publicly traded managed care organization
that delivers managed health care services
through health plans and governmentsponsored managed care plans. Its mission
is to help people be healthy, secure and
comfortable. Health Net provides and
administers health benefits to approximately
5.4 million individuals across the country
through group, individual, Medicare
(including the Medicare prescription drug
benefit commonly referred to as “Part D”),
Medicaid, U.S. Department of Defense,
including TRICARE, and Veterans Affairs
programs. Through its subsidiaries, Health
Net also offers behavioral health, substance
abuse and employee assistance programs,
managed health care products related to
prescription drugs, managed health care
product coordination for multi-region
employers, and administrative services for
medical groups and self-funded benefits
programs. For more information on Health
Net, Inc., please visit Health Net’s website at
www.healthnet.com.
Your PPA is between Health Net Federal
Services, on behalf of itself and the
subsidiaries and affiliates of Health Net, Inc.
(collectively, “Health Net”) and you.
Purpose of this Manual: Health Net’s PPN
Provider Manual is an extension of the PPA
between Health Net and Preferred Provider
Network and all provider types including,
but not limited to, physicians, hospitals, and
ancillary health care provider (“provider(s)”)
and furnishes such providers and their office
staff with information concerning policies
and procedures, claims, and guidelines used to
administer Health Net programs. This manual
replaces and supersedes the previous version
and is available at www.hnfs.com.
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 3 of 27
In accordance with the Health Net Policies
clause of the PPA, providers must abide by
all provisions contained in this manual, as
applicable. Revisions to this manual constitute
revisions to Health Net’s policies, procedures,
and programs. Revisions become binding
thirty (30) days after notice is posted on
www.hnfs.com (or provided by electronic
means), or such other period of time as
necessary for Health Net to comply with any
statutory, regulatory and/or accreditation
requirements. If a provision in this PPN
Manual conflicts with Federal, state or
municipal law or terms of your PPA, the
applicable law or your PPA will control. The
terms of this PPN Manual may be modified at
the sole discretion of Health Net.
Responsibility for Provision of Services:
Network providers are independent
contractors. Providers and Health Net do
not have an employer-employee, principalagent, partnership, joint venture, or similar
arrangement. Providers make all independent
health care treatment decisions and are
responsible for the costs, damages, claims,
and liabilities that result from their own
actions. Health Net does not endorse or
control the clinical judgment or treatment
recommendations made by providers and
not all services are contracted or covered
services. Please refer to the benefit program
requirements section for what are contracted
and covered services under programs
applicable to you.
are provided. Health Net’s prior authorization
determination relates solely to payment by
Health Net.
Health Net Products: Health Net offers
a variety of preferred provider products
through its Preferred Provider Network
to serve multiple government programs;
however, not all programs are available in all
markets. Visit www.hnfs.com, periodically, to
keep yourself abreast of updates on programs
available to you.
QUESTIONS OR COMMENTS: Questions,
comments, or suggestions regarding this
manual or its contents should be directed to:
Health Net Federal Services, LLC
Provider Network Management Department
P.O. Box 105422
Atlanta GA 30348-5422
Fax: 1-888-428-8710
Email:
HNFSProviderRelations@HealthNet.com
Health Net sometimes requires prior
authorization with respect to some services
and procedures. Health Net does this solely
for the purpose of determining whether the
services or procedures qualify for payment
under the patient’s benefit program.
Providers, along with the patient, make the
decision whether the services or procedures
Page 4 of 27
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Provider Tools
Address Change or Other
Practice Information
In order for Health Net to maintain accurate
network provider directories and also for
reimbursement purposes, all changes to
address or other practice information should
be submitted electronically via www.hnfs.
com. Notices of any changes must adhere
to time frames outlined in the Provider
Participation Agreement (PPA).
•Changes that require notice to Health Net
may include, but are not limited to, the
following:
–Provider information
–Tax identification number
–National Provider Indicator (NPI)
–Address
–Phone number
–Practice name
–Adding a provider – provider joining
practice/group
–Provider deletions – provider no longer
participating with the practice/group
–Medicare numbers
You can update your demographics using the
Provider Demographic Update Form
located at www.hnfs.com. The updated form
can be submitted by fax or emailed to:
Note: Changes to your Tax Identification
Number or group name also require
submission of an updated Form W-9 by fax to
1-888-244-4025.
For network practices adding a provider who
has not been credentialed by Health Net,
the new provider must send in a Provider
Information Form (PIF) to ensure they are
credentialed by Health Net and all data is
current and accurate. For your convenience,
a PIF can be downloaded from www.hnfs.
com. In addition, providers must have all
information current with the Council for
Affordable Quality Healthcare (CAQH®).
If you are adding a provider who has been
credentialed by Health Net within the last
three years, send us the provider’s information
by filling out a Provider Demographic
Update Form and submitting your request,
cover letter on your letterhead, by fax to
1-888-428-8710.
Health Net requires that all network
providers be recredentialed by Health Net
every three years.
www.hnfs.com
Fax: 1-888-244-4025
The Health Net Federal Services website at
www.hnfs.com provides information about PPN
benefits, processes, requirements and operations,
as well as access to business tools. Visit the VA
provider section of www.hnfs.com to:
Email:
HNFSProviderRelations@HealthNet.com
•View the Health Net PPN Provider
Handbook
Health Net Federal Services, LLC
ATTN: Provider Network Management
•Download forms
•Read important updates about PPN
programs and Health Net processes
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2
Changes in tax ID numbers may require an amendment or new participation agreement depending on the reason for the change. Visit www.hnfs.com for specific information.
If adding a provider, the new provider must first be credentialed before rendering treatment to any beneficiary.
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 5 of 27
Online Network Provider Directory
Provider Updates
An online network provider directory may be
available on the Health Net website at
www.hnfs.com, which would include:
To keep providers current about PPN
programs, products, policies, and procedures,
Health Net’s website, www.hnfs.com, includes
up-to-date information about important
program benefits, updates, and other topics.
Health Net encourages providers to visit
www.hnfs.com often for the latest PPN
program information.
•Location
•Provider name
•Provider type
•Provider specialty
•Gender
•Office phone number
•Office Fax number
•Additional language(s)
Contact
Information
Contact Us
Health Net Federal Services
Provider Relations
It is important that network providers keep
demographic information up to date to ensure
Health Net provides accurate information to
program beneficiaries and other providers.
Network providers are strongly encouraged to
visit the online network provider directory to
confirm individual listings are accurate.
ATTN: Provider Network Management
If you are a network provider and you
are not listed in the network provider
directory and you wish to be listed, please
email Provider Network Management at
HNFSProviderRelations@Healthnet.com.
Health Net Fraud Hotline: 1-800-977-6761
Fax: 1-888-244-4025
Email:
HNFSProviderRelations@HealthNet.com
Fraud, Waste and Abuse:
Most, but not all, network providers are
listed in the directory. Emergency room
physicians, urgent care physicians, and other
hospital-based providers may not be listed.
Information in the network provider directory
is subject to change without notice. Before
choosing a network provider, beneficiaries are
encouraged to call and confirm the provider is
accepting new patients.
Page 6 of 27
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Important Provider
Information
Network providers must abide by the
rules, procedures, policies and program
requirements specified in this PPN Provider
Manual and its updates, which summarize
regulations and requirements related to PPN
products programs. For more information,
visit www.hnfs.com.
General Administrative
Requirements
Office and Appointment Access Standards:
Network providers must ensure beneficiaries
receive timely care within a reasonable
distance from their homes. Emergency
services must be available 24 hours a day,
seven days a week. Providers must adhere
to the following access standards for nonemergency care:
• urgent care or acute illness appointment –
24 hours
• routine care appointment – one week (seven
calendar days) and within 30 minutes travel
time of the beneficiary’s residence
Note: A routine care appointment applies to a
treatment request for a new health condition
or exacerbation of a previous diagnosed
condition for which intervention is required,
but is not urgent.
• specialty care appointment – four weeks (28
calendar days) and within one hour travel
time from the beneficiary’s residence
• preventive care appointment – four weeks
(28 calendar days)
• Initial behavioral health care appointment
with a behavioral health care provider – one
week (seven calendar days)
•Response to urgent calls within 15 minutes
•Response to routine calls within the same
business day
•After hours, non-urgent response in 30
minutes
Office wait times for non-emergency
care appointments should not exceed 30
minutes except when the provider’s normal
appointment schedule is interrupted due to
an emergency. If running behind schedule,
notify the patient of the cause and anticipated
length of the delay and offer to reschedule the
appointment. The patient may choose to keep
the scheduled appointment or reschedule for
a future date or time.
Health Net may monitor compliance with the
access standards through a variety of ways
including telephone survey, email surveys, and
beneficiary surveys and complaints.
Note: State regulations will apply when more
stringent than these time frames.
Fraud, Waste and Abuse
Fraud, Waste and Abuse Policy: Fraud is an
intentional deception or misrepresentation of
fact that can result in unauthorized benefit or
payment.
Abuse means actions that are improper,
inappropriate, outside acceptable standards
of professional conduct or medically
unnecessary.
Health Net’s Program Integrity Department is
dedicated to combating health care fraud and
abuse committed against PPN programs. In
addition, all Health Net associates are trained
and responsible for reporting any potential or
actual fraud and abuse incidents.
Each report of potential fraud or abuse goes
through an exhaustive review process. Cases
in which there is clear evidence of intent to
defraud or serious issues concerning quality
of patient care are referred to the government
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 7 of 27
for further investigation and possible
prosecution.
In order to detect and act upon fraud or abuse
incident, Health Net:
•Formed a dedicated Program Integrity
Department and a Special Investigations
Unit.
•Implemented state of the art fraud detection
software.
•Requires all Health Net associates complete
fraud and abuse training.
•Follows reporting procedures required by
the government.
Some examples of fraud include:
•Billing for costs of non-covered or nonchargeable services, supplies, or equipment
disguised as covered items
•Billing for services, supplies or equipment
not furnished, necessary, or at a higher level
to the beneficiary
•Billing the claim for an M.D. when it was a
P.A. or N.P. delivering the services
•Duplicate billings (e.g., billing more than
once for the same service, billing the payor
and the beneficiary for the same services,
submitting claims to both the payor and
other third parties without making full
disclosure of relevant facts or immediate full
refunds in the case of overpayment by the
government payor)
•Misrepresentations of dates, frequency,
duration, description of services rendered, or
the identity of the recipient of the service or
who provided the service
•Practicing with an expired, revoked or
restricted license in any state or U.S. territory
services furnished by another provider
or furnished by the billing provider in a
capacity other than billed or claimed)
•Violation of the PPA that results in the
beneficiary being billed for amounts that
exceed the government program allowable
charge or cost
•Falsifying eligibility
Examples of abuse include:
•Pattern of waiving coinsurance/deductible
•Failure to maintain adequate medical or
financial records
•A pattern of claims for services not
medically necessary
•Refusal to furnish or allow access to medical
records
•Improper billing practices
Providers are cautioned that unbundling,
fragmenting or code gaming to manipulate
the CPT® codes as a means of increasing
reimbursement is considered an improper
billing practice and a misrepresentation of
the services rendered. Such practices can be
considered fraudulent and abusive.
Fraudulent actions can result in criminal or
civil penalties. Fraudulent or abusive activities
may result in administrative sanctions,
including suspension or termination as a
Health Net provider. Providers who engage in
fraud may also be terminated as a Medicareauthorized provider and prohibited from
participation in all federal health care
programs. The applicable government
program office of General Counsel works
in conjunction with the Program Integrity
Branch to deal with fraud and abuse.
•Reciprocal billing (i.e., billing or claiming
Page 8 of 27
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
During an investigation into any allegation of
fraud, the Program Integrity Department will
determine the following information:
•Who committed the fraud
•When the fraud occurred (time frame)
•Where the fraud occurred
•Detailed description of the fraudulent
activity
Providers can report an incident or learn
more about fraud and abuse through one of
five methods of communication:
Phone
Health Net Fraud Hotline
1-800-977-6761
Fax
1-888-881-3644
E-Mail
Program.Integrity@healthnet.com
Online
www.hnfs.com
Mail
Health Net Federal Services, LLC
ATTN: Program Integrity
P.O. Box 10490
Virginia Beach, VA 23452
Providers and their office staff are legally
required to report suspected cases of
fraud and abuse to Health Net. Entities are
protected from retaliation under 31 U.S.C.
3730(h) for False Claims Act complaints.
Health Net ensures non-retaliation against
callers and has a zero tolerance policy for
retaliation or retribution against any person
who reports suspected misconduct.
Conflicts of Interest: Providers are prohibited
from having any financial relationship relating
to the delivery of or billing for covered
services that:
•Would violate the federal Stark Law, 42.
U.S.C. § 1395nn, if health care services
delivered in connection with the relationship
were billed to a federal health care program;
or that would violate comparable state law.
•Would violate the federal Anti-Kickback
Statute, 42 U.S.C. § 1320a-7b, if health
care services delivered in connection with
the relationship were billed to a federal
health care program; or that would violate
comparable state law.
•In the judgment of Health Net, could
reasonably be expected to influence provider
to utilize or bill for covered services in a
manner that is inconsistent with professional
standards or norms in the local community.
Providers are subject to termination by Health
Net for violating this prohibition. Health Net
reserves the right to request such information
and data as it may require ascertaining
ongoing compliance with these provisions.
Beneficiary Identification (ID)
Card
Not all government programs assign
or require a beneficiary ID card (e.g.,
Department of Veterans Affairs Non-VA
Care), while others do (e.g., Medicare
Advantage). Refer to the benefit program
requirements for the programs applicable to
you for beneficiary ID card requirements and
sample images.
Covered Services
The benefit program requirements determine
whether services are covered services. To
verify covered or non-covered services, refer
to the benefit program requirements for
the programs applicable to you. All services
may be subject to applicable copayments,
coinsurance, and deductibles.
Health Net makes coverage determinations,
including medical necessity determinations,
based upon its benefit program requirements.
However, Health Net is not a provider of
medical services and it does not control
the clinical judgment or treatment
recommendations made by the providers in
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 9 of 27
its networks or who may otherwise be selected
by beneficiaries. Providers make independent
health care treatment decisions.
appropriate information in lieu of completing
Health Net’s credentialing application.
Additional information may be requested.
Note: A service must be medically necessary
and covered by the beneficiary’s benefit
program to be paid. Health Net uses the
current nationally approved criteria for any
medical necessity reviews required as well as
peer review. Not all services are contracted or
covered services.
Health Net Credentials Committee: The
Health Net Credentials Committee is
composed of a chairperson and Health
Net’s network providers. Functions of the
committee include credentialing, ongoing
and periodic assessment, recredentialing,
and establishment of credentialing and
recredentialing policies and procedures for
Health Net.
Credentialing
Credentialing is the process by which
the appropriate committee reviews
documentation for each individual provider
to determine participation in the health plan
network. Such documentation may include,
but is not limited to, the applicant’s education,
training, clinical privileges, experience,
licensure, accreditation, certifications,
professional liability insurance, malpractice
history, professional competency, and
any physical or mental impairments. The
credentialing process includes verification
that the information obtained is accurate and
complete. The provider must respond to any
reasonable Health Net request for additional
information including, but not limited to, a
medical record review as well as a site visit as
applicable.
The credentialing process generally is
required by law. The fact that the provider is
credentialed is not intended as a guarantee
or promise of any particular level of care or
service.
Council for Affordable Quality Healthcare
(CAQH): Health Net participates with the
Council for Affordable Quality Healthcare
(CAQH), which is an online single, national
process that eliminates the need for multiple
credentialing applications. Physicians and
other health care providers who are members
of CAQH can provide Health Net with the
Page 10 of 27
Minimum Criteria: Health Net conducts an
initial credentials review on each potential
network provider to determine if the provider
meets the minimum criteria. All providers
who wish to enter into an agreement with
Health Net are required to complete an
application form and participate in an
extensive review of qualifications, education,
licensure, malpractice coverage, etc. Health
Net retains the right to deny or terminate
any provider who does not meet or no longer
meets Health Net conditions of participation.
Additionally, Health Net conducts a full
recredentialing review of health care providers
every three years to help maintain current,
accurate files and to ensure all providers meet
the credentialing requirements.
There may be times between credentialing
cycles when it is appropriate to add, change or
delete a specialty description as represented
in the provider directory. To make this
change, you may need additional education
or training documentation if it was not
verified or requested during the previous
credentialing process. Please visit www.hnfs.com
for the appropriate forms, information and
instructions.
Note: Behavioral health providers should call
MHN at 1-800-541-3353 for questions about
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
joining the behavioral health network and the
MHN credentialing process.
•Agree to conditions of participation per the
Provider Participation Agreement (PPA)
Liability Insurance: Providers must maintain
their own insurance to protect themselves and
their employees against any claim resulting
from the provision of medical services. This
coverage should include, but is not limited to,
professional liability insurance in the amounts
as required by their PPA.
•Maintain professional liability coverage with
limits of at least $1 million per occurrence and
$3 million aggregate, or as listed in your PPA
Upon request, all providers are required
to provide Health Net with evidence of
insurance coverage in accordance with their
PPA requirements.
Health Net Conditions of Participation
for Network Providers: The following
summarizes the general conditions required
to participate as a network provider:
•Have a signed Medicare agreement or
participate with Medicare on a claimby-claim basis for eligible Medicare
beneficiaries
•Have active hospital privileges, in good
standing, at a Joint Commission or
Healthcare Facilities Accreditation Program
(HFAP)-accredited facility or Det Norske
Veritas (DNV)- accredited facility (May be
waived under specific conditions.)
•Have a current, valid, unrestricted Drug
Enforcement Administration (DEA)
certificate or State Controlled Substance
certificate, if applicable
•Have completed education and training
appropriate to application specialty
•Have no unexplained gaps in work history
for the most recent five (5) years
•Have malpractice history not excessive for
area and specialty
•Not be listed on the U.S. Department
of Health & Human Services, Office
of Inspector General List of Excluded
Individuals and Entities (LEIE)
•Have no felony convictions
•Have no current Medicare or Medicaid
sanctions
•Provide a SSN for all claims processing.
An Employer Identification Number
(EIN) can be provided, at the group level,
but additional information will need to
be collected for the required individual
criminal background history checks, at the
individual level
•Provide a Network Provider Identifier (NPI)
for all individuals (Type I) and entities
(Type II) billing with your organization
•Provide a service that is a covered benefit to
the program beneficiary
•Have no current disciplinary actions
(including, but not limited to, licensure and
hospital privileges)
•Sign an unmodified “Credentials Attestation,
Authorization and Release”
•Provide supporting documentation to all
confidential questions on the application (no
patient-specific PII or PHI, please)
Recredentialing: In accordance with the Health
Net credentialing and recredentialing process,
recredentialing is conducted at least every three
An Employer Identification Number (EIN) is also known as a Federal Tax Identification Number, and is used to identify a business. You can obtain your EIN,
online, from the IRS at www.EIN-gov.us.
The Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard
unique identifier for health care provider. The National Plan and Provider Enumeration System (NPPES) collects identifying information on health care providers
and assigns each a unique National Provider Identifier (NPI). You can obtain your NPI, online, from NPPES at www.nppes.cms.hhs.gov.
3
4
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 11 of 27
(3) years. Failing to respond to a recredentialing
request may result in administrative termination
from the Health Net Preferred Provider
Network.
Only licensed, qualified providers meeting
and maintaining Health Net standards for
participation requirements are retained in the
Health Net PPN.
Providers due for recredentialing must complete
all items on an approved Health Net application
form found on the Health Net website at
www.hnfs.com, and supply supporting
documentation if required. Documentation
includes, but is not limited to:
•Current state medical license
•Attestation to the ability to provide care to
Health Net beneficiaries without restriction
•Valid, unencumbered DEA certificate or
CDS certificate, if applicable. A provider who
practices medicine in more than one state must
obtain a DEA certificate for each state.
•Evidence of active admitting privileges in
good standing, with no reduction, limitation
or restriction on privileges, with at least one
Health Net network hospital or surgery center,
or a documented coverage arrangement with
a Health Net credentialed or network provider
of a like specialty
•Malpractice insurance coverage that meets
Health Net standards
•Trended assessment of provider’s beneficiary
complaints, quality of care and performance
indicators
Termination without Cause: Where required
by law, before terminating a PPA, Health Net
will provide notification to the provider. The
time frames vary as required by agreement or
applicable state and federal regulations.
Note: If a provider’s name appears on the
Page 12 of 27
current Office of the Inspector General’s (OIG)
sanctioned provider listing, the provider’s
participation agreement with Health Net will be
terminated immediately. No hearing is allowed.
Other sanctions (e.g., loss of professional
license) may result in immediate termination.
Delegation
Delegation is a formal process by which a plan
gives a provider group (delegate) the authority
to perform certain functions on its behalf, such
as credentialing, utilization management, and
claims payment. A function may be fully or
partially delegated.
Full delegation allows all activities of a function
to be delegated. Partial delegation allows some
of the activities to be delegated. The decision of
what function may be considered for delegation
is determined by the type of PPA a provider
group has with Health Net, as well as the ability
of the provider group to perform the function.
Although Health Net can delegate the authority
to perform a function, it cannot delegate the
responsibility.
Delegated Credentials/Subcontracted
Provider Functions: Network providers who
have delegation agreements with Health Net
must comply with agreement standards and
functions as they apply to credentialing of
network providers and/or other subcontracted
functions. Network providers must comply with
the following:
•Network provider’s credentialing plan, and
policies and procedures meet Health Net’s
reasonable standards, guidelines and any
required national accrediting standards
•Network provider complies with Health Net’s
credentialing criteria (credentialing standards)
•Network provider complies with applicable
state and federal regulations (including
compliance with applicable Medicare laws,
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
regulations and CMS instructions)
•Health Net retains the right to approve new
professional providers and sites, and to
terminate or suspend individual professional
participation agreements
•Current and future professional providers who
join the provider network must be properly
credentialed and recredentialed before they
may render covered services to beneficiaries
•Network provider will notify Health Net in
writing of all new professional providers
who become affiliated with and are
credentialed by him or her
•Network provider will cooperate with Health
Net’s timelines and schedules related to the
production of accurate provider directories
•Network provider will maintain all records
necessary for Health Net to monitor the
effectiveness of network provider’s credentialing
and recredentialing process, including, but not
limited to, records related to the credentialing
of all current or future professional providers
(professional provider records)
•Durable medical equipment (DME) network
providers must agree to participate with
Medicare on all dual-eligible claims
•Annually, or upon reasonable request,
a network provider will provide Health
Net with its credentialing policies and
procedures for review and evaluation and
will permit and cooperate with Health Net’s
review of network provider’s records
•Network provider will submit credentialing
and recredentialing reports that identify
those professional providers credentialed/
recredentialed, the effective date of such actions,
the most recent prior date of credentialing/
recredentialing and the effective date of such
professional provider’s participation
•Health Net retains the ultimate authority to
approve or deny any provider or site seeking
to participate with Health Net
•Health Net will have the right to audit
network provider’s performance of delegated
functions at any time and at least every three
years. Health Net reserves the right to audit
network provider as frequently as necessary
to assess performance and quality
•Health Net must be notified by network
provider of any material change in performing
delegated functions. Upon written notice,
Health Net has the right to revoke and assume
the functions and responsibilities delegated
to network provider if Health Net determines
network provider either does not or will
not have the capacity, ability, or willingness
to effectively perform, or is not effectively
performing the delegated function
•If a network provider wishes to subdelegate any delegated functions to another
organization, network provider must request
Health Net’s prior approval in a written
request. No sub-delegation may occur prior
to Health Net’s review and written approval.
At Health Net’s sole discretion, it may approve
or deny any requested sub-delegation. If
Health Net approves any sub-delegate, then
any sub-delegated function remains subject
to the terms of the delegation agreement
between network provider and Health Net.
Health Net retains ultimate oversight of any
functions of the sub-delegate
•Health Net has the right to revoke and assume
the functions and responsibilities delegated to
the network provider if the network provider
fails to comply or correct any delegated
functions within a specified period identified
by Health Net in a written notice
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 13 of 27
Prior Authorization
and Referral
Prior Authorization
and Notification
A prior authorization is a process of reviewing
certain medical, surgical and behavioral
health care services prior to services being
rendered. For example, a specific diagnostic
service, hospitalization or an invasive or
therapeutic procedure may require a prior
authorization.
Prior authorization requests must be
submitted to Health Net prior to services
being rendered.
Prior Authorization Requirements: Prior
authorization requirements vary subject
to benefit program requirements. Prior
authorization requirements are reviewed
annually in accordance with Health Net and
PPN program policy to evaluate medical and
behavioral health care trends and to better
control health care costs for the government.
See the benefit program requirements for
the programs applicable to you for prior
authorization requirements.
Referrals
A referral is the process of sending a patient
to another professional provider for medically
necessary consultations or health care services
the attending physician is not prepared or
qualified to provide. Referral services are not
considered primary care. An example of a
referral is a primary care physician sending a
patient to see a cardiologist to evaluate chest
pain.
Note: Referral requirements are based on the
benefit program. See the benefit program
requirements for the programs applicable to
you for referral requirements.
In addition, Health Net requires notification
of inpatient facility admissions and discharge
dates within 24 hours or by the next
business day following the admission and
discharge. The medical facility will receive
an authorization number after Health Net
receives a medical review and discharge date
information. To expedite claims payment,
network providers should submit the
authorization number with their claim.
If the request is not approved, the notification
letter may include a request for additional
information to determine medical necessity.
Page 14 of 27
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Claims Procedures
Claims Submission
Claims Adjudication
Electronic Claims Submission: Currently,
providers are required to use electronic
submission to submit all claims to Health Net
or its designee, as applicable, using the Health
Insurance Portability and Accountability Act
of 1996 (HIPAA) compliant 837 electronic
format or a CMS 1500 and/or UB-04, or
their successors. As new submission forms
become available, Health Net may require
a different electronic submission process.
Claims are to include the provider’s NPI and
the valid taxonomy code that most accurately
describes the services reported on the claim.
Provider acknowledges and agrees that no
reimbursement is due for a covered service
and/or no claim is complete for a covered
service unless performance of that covered
service is fully and accurately documented
in the beneficiary’s medical record prior to
the initial submission of any claim. Further,
provider acknowledges and agrees that at no
time will beneficiaries be responsible for any
payments to provider except for applicable
copayments, coinsurance, deductibles, and
non-covered services provided to such
beneficiaries.
Prompt Payment of Claims: A claim is
processed promptly if it is approved or
denied within the time required by the
PPA, benefit program requirements, or
the applicable regulation of the state in
which Health Net is operating. Most “clean
claims” (claims that comply with billing
guidelines and requirements, have no defects
or improprieties, include substantiating
documentation when applicable and do not
require special processing that would prevent
timely payment), will be processed within
30 days. Claims aged more than 30 days will
be paid interest in addition to the payable
amount.
Providers must bill using the provider’s
usual billed charges, which charges will not
discriminate based upon the identity of the
payer.
Requests for Review of Denied Claims:
If, after reconciling your accounts, you
determine payment has not been received
or you disagree with the payment amount,
do not resubmit the same claim. Instead,
explain your circumstance or disagreement
by submitting written correspondence per
the claim review process for the applicable
program.
Balance Billing: Balance billing is the practice
of a network provider billing a beneficiary
for the difference between the contracting
amount and billed charges for covered
services. When network providers contract
with Health Net, they agree to accept Health
Net’s contracting rate as payment in full.
Billing beneficiaries for any covered service
is a breach of contract, as well as a violation
of the PPA and, in some states and programs,
state and federal statutes. Participating
providers can only seek reimbursement from
Health Net beneficiaries for copayments,
coinsurance or deductibles.
Collection of Copayments and Other
Beneficiary Liabilities: Network providers
collect all copayments, coinsurance and
deductibles from beneficiaries and may
not waive or fail to pursue collection of
copayments. The network provider should
not impose any fees or surcharges on a
Health Net beneficiary for covered services
provided. If Health Net receives notice of any
additional charge, the network provider must
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 15 of 27
fully cooperate with Health Net to investigate
such allegations and promptly refund the
beneficiary any payment deemed improper by
Health Net.
Informing Beneficiaries about Non-Covered
Services: Before delivering care, network
providers must properly inform beneficiaries
in advance if services are not covered. The
beneficiary must agree in advance and
in writing to receive and accept financial
responsibility for non-covered services.
The agreement must document the specific
services, dates, estimated costs and other
information.
Certain government programs may not
allow payment for non-covered services
unless the provider has a written agreement
that documents the specific services, dates,
estimated costs and other information and
signed in advance by the beneficiary. A
general agreement to pay, such as one signed
by the beneficiary at the time of admission
is not sufficient to prove a beneficiary was
properly informed or agreed to pay. If the
beneficiary does not sign a specific written
agreement as described above, the provider
may be financially responsible for the cost of
non-covered services he or she delivers. See
the benefit program requirements for the
programs applicable to you for any specific
requirements for each benefit program.
Coding Edits: Health Net will process
provider claims that are accurate and complete
in accordance with Health Net’s normal claims
processing procedures and applicable state
and/or federal laws, rules and regulations with
respect to the timeliness of claims processing.
Such claims processing procedures and edits
may include, without limitation, automated
systems applications which identify, analyze
and compare the amounts claimed for payment
with the diagnosis codes and which analyze the
relationships among the billing codes used to
Page 16 of 27
represent the services provided to beneficiaries.
These automated systems may result in an
adjustment of the payment to the provider for
the services or in a request, prior to payment,
for the submission for review of medical
records that relate to the claim. Providers may
request reconsideration of any adjustments
produced by these automated systems by
submitting a timely request for reconsideration
to Health Net. A reduction in payment as a
result of claims policies and/or processing
procedures is not an indication that the service
provided is a non-covered service.
Claims Adjustment
Procedures
Claims adjustment procedures are programspecific and requests must be made in writing.
Adjustment determinations are made on a
claim-by-claim basis.
Before submitting a request for claim
adjustment, first review your Health Net PPN
PPA and the applicable rate exhibits.
Key pieces of information to include with
your request:
•Provider Tax Identification Number (or SSN,
as appropriate)
•Provider name and group name
•Legal point of contact name, address,
telephone number, fax number, and email
address
•Single claim:
–Copy of disputed claim
–Copy of Remit Advice
–Reason for dispute
•Multiple claims (must be submitted in an
MS Excel spreadsheet to include):
–Provider TIN/SSN
–Provider name
–Claim number
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
–Date of service
can show proof of timely claim filing, Health
Net gives consideration to other provider
claim adjustments. Other adjustment policy
guidelines include:
–Billed amount
–Paid amount
–Reason for dispute
Note: Communications containing claims
detail are confidential and must be marked as
such and managed, appropriately.
Timely Filing Criteria
If a claim is denied for timely filing, but the
provider can demonstrate good cause for the
delay, Health Net may choose to accept and
adjudicate the claim as if it were submitted
in a timely manner. Health Net considers
and determines whether or not there is a
good cause for the delay using standardized
guidelines.
Good Cause for Delay Guidelines: Good
cause for claim submission delays for
providers who receive misinformation from
beneficiaries or Health Net that causes timely
filing claim denials must fall under the
following guidelines:
•The delay was not reasonably in the
provider’s sole ability to control. For
example:
•The provider submits proof in the form of
one of the following:
–Electronic Data Interchange (EDI) confirmation that Health Net received and
accepted the claim
–Delivery confirmation evidence (e.g., registered receipt or certified mail receipt to a
Health Net address)
Reimbursement
Payments made to network providers for
medical services rendered to PPN program
beneficiaries will not exceed 100 percent of
the payment terms defined in the PPA. All
reimbursement methodologies are impacted
by a network provider’s negotiated discount
rate. A provider will not receive 100 percent
of a program’s allowable charge if they have a
negotiated discount. The amount of payment
for services provided is affected not only by the
terms in the PPA, but also by the following:
•Beneficiary’s eligibility at the time of service
–The provider received misinformation
from the beneficiary and the provider is
submitting one of the following:
–Patient information form and/or beneficiary identification (ID) card presented by
the Health Net beneficiary
–Explanation of Benefit from incorrect carrier
•The provider has followed Health Net
instructions.
•Whether services provided are covered
services under the beneficiary’s plan
•Whether services provided are medically
necessary as required by the beneficiary’s plan
•Whether services were without the prior
approval of Health Net, if prior approval is
required by the benefit program
•Amount of the provider’s billed charges
•Circumstances existed that the provider
could not foresee or prevent.
•The delay was not the result of the provider’s
negligent or willful action or inaction.
Adjustment Guidelines: For providers who
•Beneficiary copayments, coinsurance,
deductibles, and other coinsurance amounts
due from the beneficiary and coordination
of benefits with third-party payors as
applicable
•Adjustments of payments based on coding
edits described above
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 17 of 27
Note: With some claims, additional
information may justify additional payment.
For example, a provider’s clinical notes
may establish that a procedure code judged
incidental to another in Health Net’s
automated process actually involved a
distinct and significant provider effort, in the
circumstances of the provider’s encounter
with his or her patient. If a provider believes
that Health Net’s automated process has
adjudicated a claim incorrectly, the provider
should follow the procedures for appealing
the denial described above under Coding
Edits, or if applicable, any laws or programspecific guidelines regarding grievance and
appeals processes. Please include a copy of
the applicable clinical notes with physician/
provider appeal.
Nothing contained in the PPA or this manual
is intended by Health Net to be a financial
incentive or payment which directly or
indirectly acts as an inducement for providers
to limit medically necessary services.
Note: Health Net applies the Centers for
Medicare & Medicaid (CMS) site-of-service
payment differentials in its fee schedules for
CPT codes based on the place of treatment
(physician office services versus other places
of treatment).
Network providers are to accept payment
from Health Net for covered services provided
to health plan beneficiaries in accordance with
the reimbursement terms outlined in the PPA.
Beneficiaries are responsible for their outof-pocket expenses including deductible,
coinsurance and/or copayment amounts. For
covered services, providers may not balance
bill beneficiaries for a monetary amount over
or above the fee schedule provided in their
PPA; however, they are not prohibited by the
Page 18 of 27
PPA from collecting from beneficiaries for
any services not covered under the terms of
the applicable beneficiary plan. A reduction
in payment as a result of claims policies and/
or processing procedures is not an indication
that the service provided is a non-covered
service.
Fee Schedule: Fee Schedule information may
be found at www.hnfs.com. Reimbursement
methodologies for your Health Net Provider
Participaton Agreement (PPA) are found in
the applicable PPA rate exhibits.
Services Which Are Not Medically
Necessary: Provider agrees that in the event
of a denial of payment for services rendered to
beneficiaries determined not to be medically
necessary by Health Net, that provider will
not bill, charge, seek payment or have any
recourse against beneficiary for such services,
unless specifically agreed to in writing by
beneficiary, as described above.
Provider Overpayments: If a provider is aware
of receiving an overpayment from Health Net,
including but not limited to, overpayment
caused by incorrect or duplicate payment,
errors on or changes to provider billing, or
payment by another payer who is responsible
for primary payment, the provider must
promptly refund the overpayment amount to
Health Net at the following address:
Health Net Federal Services, LLC
ATTN: CLAIMS ADMINISTRATION –
OVERPAYMENT
2025 Aerojet Rd
Rancho Cordova CA 95742
The refund should contain a copy of the
applicable Remittance Advice (RA) and a
information indicating why the amount is
being returned. If the RA is not available,
provide beneficiary name, date of service,
payment amount, Health Net beneficiary
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
identification (ID) number, provider Tax
Identification Number (TIN) and National
Provider Identifier (NPI).
Office Procedures
When Health Net determines that an
overpayment has occurred, Health Net
notifies the provider of services in writing
within 365 days of the date of learning of the
overpaid claim through a separate notice that
includes the following information:
This section provides policies and procedures
that pertain to the daily operations of
a provider office. Health Net provider
representatives shall be permitted access to
the provider’s office records and operations.
This access allows Health Net to monitor
compliance with regulatory requirements.
•Beneficiary name
Medical Records
•Claim ID number
Health Net may review medical records on a
random basis to evaluate patterns of care and
compliance with performance standards. Each
provider should have policies and procedures
in place to help ensure the information
in each patient’s medical record is kept
confidential and is appropriately organized.
The medical record must contain information
to justify admission and continued
hospitalization, support the diagnosis and
describe the patient’s progress and response to
medications and services.
•Explanation of why Health Net believes the
claim was overpaid
•Amount of overpayment, including interest
and penalties
The 365 day time period does not apply to
overpayments caused in whole or in part by
fraud or provider misrepresentation.
The provider of service has 30 business days
to submit a written dispute to Health Net if
the provider does not believe an overpayment
has occurred. In this case, Health Net treats the
claim overpayment issue as a provider dispute.
Health Net may recoup uncontested
overpayments by offsetting overpayments
from payments for a provider’s current claims
for services if:
•The provider’s PPA authorizes it to offset
overpayments from payments for current
claims for services
•Otherwise permitted under state laws
A written notification is sent to the provider
of service if an overpayment is recouped
through offsets to claims payments.
The notification identifies the specific
overpayment and the claim identification
(ID) number.
The provider’s medical records must be
available for utilization, risk management,
peer review studies, customer service
inquiries, grievance and appeal processing,
and other initiatives Health Net may be
required to conduct. To comply with
accreditation and regulatory requirements,
periodically Health Net may perform a
documentation audit of some provider
medical records.
Note: The network provider must respond
to the Health Net grievance and appeal unit
expeditiously with submission of the required
medical records.
Only those records for the time period
designated on the request should be sent. A
copy of the request letter should be submitted
with the copy of the record. The submission
should include test results, office notes,
referrals, telephone logs, and consultation
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 19 of 27
reports. Medical records should not be
submitted by fax unless provider can ensure
confidentiality of those medical records.
To be compliant with HIPAA, providers
should make reasonable efforts to restrict
access and limit routine disclosure of
protected health information (PHI) to
the minimum necessary to accomplish
the intended purpose of the disclosure of
beneficiary information.
Note: Charges for copying medical records
are considered a part of office overhead and
are to be provided at no cost to beneficiaries
and Health Net, unless state regulations or
municipal ordinances stipulate differently.
Clinical Information
Submission
Health Net does not routinely require or
request clinical information at the time of
claim submission.
Provider Inquiries
An inquiry is a verbal or written
question for clarification (such as a
request for information), without an
expression of dissatisfaction or request for
reconsideration. Providers may contact
Health Net or its designee, as applicable
when wanting to:
• Inquire regarding the status of a claim or
obtain payment calculation clarification
• Resubmit contested claims with the missing
information requested by Health Net
• Submit a corrected claim (additional
charges previously not submitted)
• Clarify member responsibility
Provider inquiry contact information is
program-specific and can be located at
www.hnfs.com.
Health Net reserves the right to request
clinical records before or after claim payment
to comply with program requirements or to
identify possible fraudulent or abusive billing
practices, as well as any other inappropriate
billing practice not compliant with the AMA
CPT codes or guidelines.
Note: Refer to the benefit program
requirements for the programs applicable
to you for Clinical Information Submission
requirements.
Page 20 of 27
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Grievances and
Appeals/Disputes
The grievance and appeal/dispute processes
apply to providers and beneficiaries who
are dissatisfied with the health care services
received, or any aspect of the program. These
processes are designed to resolve complaints
or disputes regarding adverse determinations.
If the initial grievance or appeal is denied,
the resolution letter will provide next level
rights as applicable. Certain states and
federal programs may have specific processes
for physician grievance or appeal requests.
Physicians may utilize the beneficiary’s
grievance or appeal process by obtaining
authorization from the beneficiary.
The fact that a member submits a grievance
or appeal to Health Net or the network
provider should not affect in any way the
manner in which the member is treated by the
network provider. If Health Net discovers that
any improper action has been taken against
such a member by the network provider,
Health Net will take immediate steps to
prevent such conduct in the future. These
steps involve appropriate sanctions, including
possible termination of the applicable
Provider Participation Agreement (PPA).
Grievances
A grievance is a written complaint or concern
about a medical provider, Health Net or
Health Net associate, or a PPN program, in
general. Appeals, disputes and claim review
issues are separate from grievances. View the
Appeals/Disputes section to the right and
the Claims Procedures section on page 15 for
additional information. Note: If a program
attachment or addendum is applicable,
providers should follow those program-specific
grievance processes.
The Health Net grievance process allows full
opportunity for any program beneficiary,
beneficiary’s representative, and network or
non-network provider to report in writing
any concern or complaint (grievance)
regarding health care quality or service. Note:
Beneficiaries submit grievances through the
applicable program-specific grievance process.
Required Information for Grievances:
A description of the issue or concern must
include:
• The date and time of the event
• Name of the provider(s) and/or person(s)
involved
• Location of the event (address)
• The nature of the concern or complaint
• Details describing the event or issue
• Any appropriate supporting documents
Submit an HNFS PPN Grievance Form or a
letter outlining the grievance information
Fax
1-888-244-4025
Email HNFSProviderRelations@HealthNet.com
The HNFS PPN Grievance Form is located
at www.hnfs.com. listed above in one of the
following ways:
Appeals/Disputes
An appeal or dispute is a verbal or written
request to change a previous service decision
or adverse determination (a determination
that a health care service is not covered or
is not medically necessary). The request can
be from a network provider, beneficiary or
a beneficiary representative. Note: Programspecific guidelines dictate whether a service
decision or determination is appealable
and by whom. Refer to the dispute/appeal
requirements for the programs applicable
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 21 of 27
to you. Disputes/appeals regarding claims
or prior authorizations and referrals must
be submitted through the program-specific
appeals process.
•If the dispute is not about a claim, the
provider must include a clear explanation
of the reason for the dispute, including if
applicable, relevant references to the PPA.
Dispute Submission: Health Net complies
with all applicable state and federal law with
respect to providers disputes. The dispute
resolution process may vary by Program and/or
as mandated by applicable state or federal law.
Refer to the benefit program requirements for
the programs applicable to you.
A provider dispute submitted on behalf of a
beneficiary is considered a beneficiary appeal
and is processed through the beneficiary
appeal process.
In the absence of applicable state, federal or
program specific requirements, Health Net
accepts disputes, including appeals, from
network providers if they are submitted
within 90 calendar days of receipt of Health
Net’s decision (for example, denial or
adjustment), except as described below. If the
network provider does not receive a decision
from Health Net within 60 calendar days, the
dispute is deemed rejected. Rejected claims
may be resubmitted within 90 calendar
days contesting Health Net’s decision. If
the network provider’s PPA provides for a
dispute-filing deadline that is greater than
90 calendar days, this longer time frame
continues to apply until the agreement is
amended. The provider dispute must comply
with the following:
•The dispute must include the provider’s
name, identification (ID) number, contact
information, including telephone number,
and the original claim number.
•If the dispute is regarding a claim or
a request for reimbursement of an
overpayment of a claim, the dispute must
include: clear identification of the disputed
item, the date of service, and a clear
explanation as to why the provider believes
the payment amount, request for additional
information, request for reimbursement of
an overpayment or other action is incorrect.
Page 22 of 27
Health Net resolves provider disputes within
60 business days following receipt of the
dispute and sends the provider a written
determination stating the reasons for the
determination. If the provider dispute
submission does not include all pertinent
details of the dispute, it will be returned to
the provider with a request detailing the
additional information required to resolve
the issue. The amended dispute must be
submitted with the missing information
within 30 business days from date of receipt
of the request for additional information.
Providers are not asked to resubmit claim
information or supporting documentation
previously submitted to Health Net as part of
the claims adjudication process, unless Health
Net returned the information to the provider.
If the provider dispute involving a claim for a
provider’s services is resolved in favor of the
provider, Health Net pays any outstanding
money due, including any required interest
or penalties, within 21 business days of the
decision. Accrual of the interest and penalties,
if any, commences on the day following the
date by which the claim or dispute should
have been processed.
Network providers who have an agreement
to work directly with Health Net and disagree
with Health Net’s determination may refer
to their PPA for other available means of
resolution.
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Contractual Disputes
Health Net strives to informally resolve
issues raised by providers on initial contact
whenever possible. If issues cannot be
resolved informally, Health Net offers
an internal appeal process for resolving
contractual disputes. Following the internal
Health Net process, arbitration may be used
as a final resolution step.
Contractual disputes must be submitted in
writing within 90 calendar days of the date of
the occurrence.
Submit your contractual dispute by fax or
email to:
Health Net Federal Services, LLC
ATTN: Provider Network Management
Fax: 1-888-244-4025
Email:
HNFSProviderRelations@HealthNet.com
If a decision is made to uphold the initial
decision, an appeal-denial letter will be sent
to the provider outlining any additional
appeal rights.
Health Care
Management and
Administration
Network providers must participate in and
cooperate with the health care management
programs required by the benefit plan.
Medical records requested in connection with
these programs must be provided at no charge
and within the time frames requested which
time frame must be reasonable under the
circumstances, unless otherwise required by
your provider agreement.
Unless otherwise required by law or your PPA,
payment may be denied for failure to comply
with health care management requirements,
and providers cannot bill beneficiaries for any
such denied payments. In addition, failure to
comply may result in disciplinary action up to
and including removal from the network and/
or termination of the PPA.
Utilization Management
Utilization Management (UM) is a process
that manages the beneficiary at the point of
care through prospective review, concurrent
review, retrospective review, case management
and discharge-planning activities. Health
Net may conduct UM activities on covered
services subject to benefit program
requirements.
Case Management
The Case Management Program, if applicable,
coordinates all aspects of medical and
behavioral health treatment by directing
at-risk beneficiaries who require extensive,
complex and/or costly services to the most
appropriate levels of care necessary for
effective treatment. By linking many services,
including the government program resources,
the case manager can coordinate treatment
to provide cost-effective, quality care. Health
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Page 23 of 27
Net conducts case management activities on
covered services subject to benefit program
requirements.
Policy on Separation of
Medical Decisions and
Financial Concerns
Clinical Quality Management
Health Net has a strict policy:
Health Net is committed to providing the highest
quality health care possible to PPN program
beneficiaries by partnering with network
providers who share this goal. In compliance
with government program requirements, Health
Net has a CQM program for assessing and
monitoring care and services rendered to PPN
program beneficiaries throughout the health care
delivery system. Health Net conducts clinical
quality management (CQM) activities on covered
services subject to benefit program requirements.
•UM decisions are based on medical necessity
and medical appropriateness
Discharge Planning
As the patient’s illness decreases in severity
and/or begins to stabilize, the intensity
of services will reflect that. If care may be
delivered in a less emergency-oriented setting,
the medical management staff will coordinate
efforts with the physician directing the care
(and the patient and family members) to
facilitate timely and appropriate discharge.
Refer to the benefit program requirements for
the programs applicable to you to determine if
Discharge Planning is required.
Page 24 of 27
•Health Net does not compensate physicians
or nurse reviewers for denials
•Health Net does not offer incentives to
encourage coverage or service denial
•Special concern and attention should be paid
to underutilization risk
Medical decisions regarding the nature and
level of care to be provided to a beneficiary,
including the decision of who will render the
service (e.g., primary care physician versus
specialist, network provider versus nonnetwork provider), must be made by qualified
medical providers, and unhindered by fiscal or
administrative concerns. Health Net monitors
compliance with this requirement as part of
its quality-improvement process.
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Rights and
Responsibilities
Beneficiary Rights and
Responsibilities
Health Net adheres to certain rules of
accrediting and regulatory agencies
concerning beneficiary rights. PPN
program beneficiaries have certain
rights and responsibilities when being
treated by network providers. The rights
and responsibilities statement reminds
beneficiaries and providers of their
complementary roles in maintaining a
productive relationship.
PPN program beneficiaries have the right to:
Get information – Beneficiaries have the
right to receive accurate, easy-to-understand
information from written materials,
presentations and program representatives
to help them make informed decisions about
PPN programs, medical professionals and
facilities.
Choose providers and programs –
Beneficiaries have the right to a choice of
health care providers sufficient to ensure
access to appropriate, high-quality health
care.
Emergency care – Beneficiaries have the right
to access emergency health care services when
and where the need arises.
Participate in treatment – Beneficiaries have
the right to receive and review information
about the diagnosis, treatment and progress
of their condition. Beneficiaries have the right
to fully participate in all decisions related
to their health care, or be represented by
family members, conservators or other duly
appointed representatives.
Respect and nondiscrimination –
Beneficiaries have the right to receive
considerate, respectful care from all
members of the health care system without
discrimination based on race, ethnicity,
national origin, religion, sex, age, mental or
physical disability, sexual orientation, genetic
information, or source of payment.
Confidentiality of health information –
Beneficiaries have the right to communicate
with health care providers in confidence and
to have the confidentiality of their health care
information protected as required by law.
They also have the right to review, copy, and
request amendments to their medical records.
Complaints and appeals – Beneficiaries have
the right to a fair and efficient process for
resolving differences with their health plans,
health care providers and the institutions that
serve them.
PPN program beneficiaries have the
responsibility to:
Maximize health – Beneficiaries have
the responsibility to maximize healthy
habits, such as exercising, not smoking and
maintaining a healthy diet.
Make smart health care decisions –
Beneficiaries have the responsibility to
be involved in health care decisions. This
means working with providers to develop
and carry out agreed-upon treatment plans,
disclosing relevant information and clearly
communicating wants and needs.
Be knowledgeable about benefit program
requirements – Beneficiaries have the
responsibility to be knowledgeable about
benefit program requirements and options.
PPN program beneficiaries also have the
responsibility to:
•Show respect for other patients and health
care workers
Health Net Preferred Provider Network (PPN) Provider Manual March 2015
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•Make a good-faith effort to meet financial
obligations
•Use the disputed claims process when there
is a disagreement
•Report wrong doing and fraud to
appropriate resources or legal authorities
•Pay copayments, coinsurance and
deductibles
•Pay for non-covered services (if the
beneficiary agreed in advance and in writing
to pay for these services)
•Pay all charges if ineligible for program
benefits at the time of service
Professional Conduct during Physical
Examination of Program Beneficiaries:
The beneficiary or provider may request a
chaperon to be present during any office
examination. The chaperon may be a family
beneficiary or friend of the beneficiary, or the
physician’s/provider’s assistant. Prior to an
examination of a minor, the physician should
obtain a parent or guardian’s consent in the
manner specified by the state.
Note: Some states have regulations that
may conflict with these guidelines. In those
incidences, state regulations, if more stringent,
shall take precedence over these guidelines.
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Health Net Preferred Provider Network (PPN) Provider Manual March 2015
Index
Abuse........................................................6, 7, 8
Health Net Program Integrity Department...... 7
Address Change............................................... 5
Health Net, Inc................................................ 3
Appeal.................................................18, 21, 22
www.hnfs.com................................................. 5
Balance Billing............................................... 15
Liability Insurance........................................ 10
Beneficiary Identification (ID) Card.............. 9
Medical Records............................................ 19
Beneficiary Rights and Responsibilities....... 25
Non-Covered Services.................................. 16
CAQH........................................................ 5, 10
Office Procedures.......................................... 19
Case Management......................................... 23
Other Adjustments Guidelines..................... 17
Claims Adjudication..................................... 15
PIF..................See Provider Information Form
Claims Adjustment....................................... 16
PPN................See Preferred Provider Network
Claims Procedures........................................ 15
Preferred Provider Network........................... 3
Clinical Information Submission................. 20
Prior Authorization....................................... 14
Clinical Quality Management...................... 24
Prompt Payment of Claims.......................... 15
Coding Edits.................................................. 16
Provider Demographics Update Form.......... 5
Comments....................................................... 4
Provider Directory.......................................... 6
Conditions of Participation.......................... 10
Provider Information Form........................... 5
Contact Us....................................................... 6
Provider Overpayments................................ 18
Covered Services............................................. 9
Questions......................................................... 4
Credentialing............................................. 3, 10
Recredentialing.............................................. 10
Delegation..................................................... 12
Referrals......................................................... 14
Discharge Planning....................................... 23
Reimbursement............................................. 17
Dispute Submission...................................... 22
Requests for Review of Denied Claims........ 15
Electronic Claims Submission...................... 15
Fee Schedule.................................................. 18
Separation of Medical Decisions and Financial
Concerns........................................................ 24
Fraud..................................................6,7, 19, 26
Termination without Cause.......................... 12
Good Cause for Delay Guidelines................ 17
Timely Filing Criteria................................... 17
Grievance....................................................... 21
Updates............................................................ 6
Health Net Federal Services, LLC................... 3
Utilization Management............................... 23
Health Net Products....................................... 4
VH0215x033Health
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