Preferred Provider Network Provider Manual

Preferred Provider Network Provider Manual

Health Net Federal Services

March 2015

Health Net Preferred Provider Network (PPN) Provider Manual March 2015 of 27

Contents Overview ............................................................................3Provider Tools .....................................................................5

Address Change Or Other Practice Information ....................................................................... 5

www.hnfs.com ............................................................................................................................. 5

Online Network Provider Directory ................................................................................... 6

Provider Updates ................................................................................................................. 6

Contact Information ............................................................6Contact Us .................................................................................................................................... 6

Important Provider Information ..........................................7General Administrative Requirements ....................................................................................... 7

Fraud, Waste And Abuse .............................................................................................................. 7

Beneficiary Identification (ID) Card .......................................................................................... 9

Covered Services .......................................................................................................................... 9

Credentialing.............................................................................................................................. 10

Delegation .................................................................................................................................. 12

Prior Authorization And Referral ......................................14Prior Authorization And Notification ...................................................................................... 14

Referrals ...................................................................................................................................... 14

Claims Procedures ............................................................15Claims Submission .................................................................................................................... 15

Claims Ajudication .................................................................................................................... 15

Claims Adjustment Procedures ................................................................................................. 16

Timely Filing Criteria ................................................................................................................ 17

Reimbursement .......................................................................................................................... 17

Office Procedures .............................................................19Medical Records ......................................................................................................................... 19

Clinical Information Submission ............................................................................................. 20

Provider Inquries ...............................................................20Grievances And Appeals/Disputes ....................................21

Grievances .................................................................................................................................. 21

Appeals/Disputes ....................................................................................................................... 21

Contractual Disputes ................................................................................................................. 23

Health Care Management And Administration .................23Utilization 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 ...............................................25Beneficiary Rights And Responsibilities ................................................................................... 25

Index .................................................................................27


OverviewAbout 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 government-

sponsored 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.


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, principal-

agent, 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.

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

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:

[email protected]


Provider ToolsAddress Change or Other Practice InformationIn 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).

•ChangesthatrequirenoticetoHealthNet

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:


ATTN: Provider Network Management

Fax: 1-888-244-4025

Email:

[email protected]

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.comThe 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:

•ViewtheHealthNetPPNProvider

Handbook

•Downloadforms

•ReadimportantupdatesaboutPPN

programs and Health Net processes

1 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.2 If adding a provider, the new provider must first be credentialed before rendering treatment to any beneficiary.

https://www.hnfs.com/content/hnfs/home/va/home/provider/preferred-provider-network-forms/demographic-updates.html#form_1376606636099

https://www.hnfs.com/content/hnfs/home/va/home/provider/preferred-provider-network-forms/credentialing.html#form_1376666928478

http://www.irs.gov/pub/irs-pdf/fw9.pdf

http://www.caqh.org/

https://www.hnfs.com/content/hnfs/home/va/home/provider/preferred-provider-network-forms/demographic-updates.html#form_1376606636099


Online Network Provider Directory

An online network provider directory may be

available on the Health Net website at

www.hnfs.com, which would include:

•Location

•Providername

•Providertype

•Providerspecialty

•Gender

•Officephonenumber

•OfficeFaxnumber

•Additionallanguage(s)

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.

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

[email protected].

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.

Provider Updates

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.

Contact InformationContact UsHealth Net Federal Services

Provider Relations


Fax: 1-888-244-4025

Email:

[email protected]

Fraud, Waste and Abuse:

Health Net Fraud Hotline: 1-800-977-6761


Important Provider InformationNetwork 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 RequirementsOffice 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 non-

emergency care:

•urgentcareoracuteillnessappointment–

24 hours

•routinecareappointment–oneweek(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.

•specialtycareappointment–fourweeks(28

calendar days) and within one hour travel

time from the beneficiary’s residence

•preventivecareappointment–fourweeks

(28 calendar days)

•Initialbehavioralhealthcareappointment

withabehavioralhealthcareprovider–one

week (seven calendar days)

•Responsetourgentcallswithin15minutes

•Responsetoroutinecallswithinthesame

business day

•Afterhours,non-urgentresponsein30

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


for further investigation and possible

prosecution.

In order to detect and act upon fraud or abuse

incident, Health Net:

•FormedadedicatedProgramIntegrity

Department and a Special Investigations

Unit.

•Implementedstateoftheartfrauddetection

software.

•RequiresallHealthNetassociatescomplete

fraud and abuse training.

•Followsreportingproceduresrequiredby

the government.

Some examples of fraud include:

•Billingforcostsofnon-coveredornon-

chargeable services, supplies, or equipment

disguised as covered items

•Billingforservices,suppliesorequipment

not furnished, necessary, or at a higher level

to the beneficiary

•BillingtheclaimforanM.D.whenitwasa

P.A. or N.P. delivering the services

•Duplicatebillings(e.g.,billingmorethan

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)

•Misrepresentationsofdates,frequency,

duration, description of services rendered, or

the identity of the recipient of the service or

who provided the service

•Practicingwithanexpired,revokedor

restricted license in any state or U.S. territory

•Reciprocalbilling(i.e.,billingorclaiming

services furnished by another provider

or furnished by the billing provider in a

capacity other than billed or claimed)

•ViolationofthePPAthatresultsinthe

beneficiary being billed for amounts that

exceed the government program allowable

charge or cost

•Falsifyingeligibility

Examples of abuse include:

•Patternofwaivingcoinsurance/deductible

•Failuretomaintainadequatemedicalor

financial records

•Apatternofclaimsforservicesnot

medically necessary

•Refusaltofurnishorallowaccesstomedical

records

•Improperbillingpractices

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 Medicare-

authorized 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.


During an investigation into any allegation of

fraud, the Program Integrity Department will

determine the following information:

•Whocommittedthefraud

•Whenthefraudoccurred(timeframe)

•Wherethefraudoccurred

•Detaileddescriptionofthefraudulent

activity

Providers can report an incident or learn

more about fraud and abuse through one of

five methods of communication:

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:

•WouldviolatethefederalStarkLaw,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.

PhoneHealth Net Fraud Hotline1-800-977-6761

Fax 1-888-881-3644

E-Mail [email protected]

Online www.hnfs.com

Mail

Health Net Federal Services, LLCATTN: Program IntegrityP.O. Box 10490Virginia Beach, VA 23452

•WouldviolatethefederalAnti-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.

•InthejudgmentofHealthNet,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) CardNot 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 ServicesThe 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


its networks or who may otherwise be selected

by beneficiaries. Providers make independent

health care treatment decisions.

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.

CredentialingCredentialing 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

appropriate information in lieu of completing

Health Net’s credentialing application.

Additional information may be requested.

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.

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


joining the behavioral health network and the

MHN credentialing process.

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.

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:

•HaveasignedMedicareagreementor

participate with Medicare on a claim-

by-claim basis for eligible Medicare

beneficiaries

•NotbelistedontheU.S.Department

of Health & Human Services, Office

of Inspector General List of Excluded

Individuals and Entities (LEIE)

•ProvideaSSNforallclaimsprocessing.

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

•ProvideaNetworkProviderIdentifier(NPI)

for all individuals (Type I) and entities

(Type II) billing with your organization

•Provideaservicethatisacoveredbenefitto

the program beneficiary

•Agreetoconditionsofparticipationperthe

Provider Participation Agreement (PPA)

•Maintainprofessionalliabilitycoveragewith

limits of at least $1 million per occurrence and

$3 million aggregate, or as listed in your PPA

•Haveactivehospitalprivileges,ingood

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.)

•Haveacurrent,valid,unrestrictedDrug

Enforcement Administration (DEA)

certificate or State Controlled Substance

certificate, if applicable

•Havecompletededucationandtraining

appropriate to application specialty

•Havenounexplainedgapsinworkhistory

for the most recent five (5) years

•Havemalpracticehistorynotexcessivefor

area and specialty

•Havenofelonyconvictions

•HavenocurrentMedicareorMedicaid

sanctions

•Havenocurrentdisciplinaryactions

(including, but not limited to, licensure and

hospital privileges)

•Signanunmodified“CredentialsAttestation,

Authorization and Release”

•Providesupportingdocumentationtoall

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

3 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.4 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) 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:

•Currentstatemedicallicense

•Attestationtotheabilitytoprovidecareto

Health Net beneficiaries without restriction

•Valid,unencumberedDEAcertificateor

CDS certificate, if applicable. A provider who

practices medicine in more than one state must

obtain a DEA certificate for each state.

•Evidenceofactiveadmittingprivilegesin

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

•Malpracticeinsurancecoveragethatmeets

Health Net standards

•Trendedassessmentofprovider’sbeneficiary

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

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.

DelegationDelegation 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:

•Networkprovider’scredentialingplan,and

policies and procedures meet Health Net’s

reasonable standards, guidelines and any

required national accrediting standards

•NetworkprovidercomplieswithHealthNet’s

credentialing criteria (credentialing standards)

•Networkprovidercomplieswithapplicable

state and federal regulations (including

compliance with applicable Medicare laws,


regulations and CMS instructions)

•HealthNetretainstherighttoapprovenew

professional providers and sites, and to

terminate or suspend individual professional

participation agreements

•Currentandfutureprofessionalproviderswho

join the provider network must be properly

credentialed and recredentialed before they

may render covered services to beneficiaries

•NetworkproviderwillnotifyHealthNetin

writing of all new professional providers

who become affiliated with and are

credentialed by him or her

•NetworkproviderwillcooperatewithHealth

Net’s timelines and schedules related to the

production of accurate provider directories

•Networkproviderwillmaintainallrecords

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)

•Durablemedicalequipment(DME)network

providers must agree to participate with

Medicare on all dual-eligible claims

•Annually,oruponreasonablerequest,

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

•Networkproviderwillsubmitcredentialing

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

•HealthNetretainstheultimateauthorityto

approve or deny any provider or site seeking

to participate with Health Net

•HealthNetwillhavetherighttoaudit

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

•HealthNetmustbenotifiedbynetwork

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

•Ifanetworkproviderwishestosub-

delegate 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

•HealthNethastherighttorevokeandassume

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


Prior Authorization and ReferralPrior Authorization and NotificationA 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.

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.

ReferralsA 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.


Claims ProceduresClaims SubmissionElectronic 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.

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.

Claims AdjudicationPrompt 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.

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


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

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 ProceduresClaims adjustment procedures are program-

specific 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.

Keypiecesofinformationtoincludewith

your request:

•ProviderTaxIdentificationNumber(orSSN,

as appropriate)

•Providernameandgroupname

•Legalpointofcontactname,address,

telephone number, fax number, and email

address

•Singleclaim:

– Copy of disputed claim– Copy of Remit Advice– Reason for dispute

•Multipleclaims(mustbesubmittedinan

MS Excel spreadsheet to include):

– Provider TIN/SSN– Provider name– Claim number


– Date of service– 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 CriteriaIf 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:

•Thedelaywasnotreasonablyinthe

provider’s sole ability to control. For

example:

– The provider received misinformation from the beneficiary and the provider is submitting one of the following:

– Patient information form and/or benefi-ciary identification (ID) card presented by the Health Net beneficiary

– Explanation of Benefit from incorrect car-rier

•TheproviderhasfollowedHealthNet

instructions.

•Circumstancesexistedthattheprovider

could not foresee or prevent.

•Thedelaywasnottheresultoftheprovider’s

negligent or willful action or inaction.

Adjustment Guidelines: For providers who

can show proof of timely claim filing, Health

Net gives consideration to other provider

claim adjustments. Other adjustment policy

guidelines include:

•Theprovidersubmitsproofintheformof

one of the following:

– Electronic Data Interchange (EDI) con-firmation that Health Net received and accepted the claim

– Delivery confirmation evidence (e.g., reg-istered receipt or certified mail receipt to a Health Net address)

ReimbursementPayments 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’seligibilityatthetimeofservice

•Whetherservicesprovidedarecovered

services under the beneficiary’s plan

•Whetherservicesprovidedaremedically

necessary as required by the beneficiary’s plan

•Whetherserviceswerewithouttheprior

approval of Health Net, if prior approval is

required by the benefit program

•Amountoftheprovider’sbilledcharges

•Beneficiarycopayments,coinsurance,

deductibles, and other coinsurance amounts

due from the beneficiary and coordination

of benefits with third-party payors as

applicable

•Adjustmentsofpaymentsbasedoncoding

edits described above


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 program-

specific 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 out-

of-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

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:


ATTN:CLAIMSADMINISTRATION–

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


identification (ID) number, provider Tax

Identification Number (TIN) and National

Provider Identifier (NPI).

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:

•Beneficiaryname

•ClaimIDnumber

•ExplanationofwhyHealthNetbelievesthe

claim was overpaid

•Amountofoverpayment,includinginterest

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:

•Theprovider’sPPAauthorizesittooffset

overpayments from payments for current

claims for services

•Otherwisepermittedunderstatelaws

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.

Office ProceduresThis 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.

Medical Records 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.

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


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 SubmissionHealth Net does not routinely require or

request clinical information at the time of

claim submission.

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.

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:

•Inquireregardingthestatusofaclaimor

obtain payment calculation clarification

•Resubmitcontestedclaimswiththemissing

information requested by Health Net

•Submitacorrectedclaim(additional

charges previously not submitted)

•Clarifymemberresponsibility

Provider inquiry contact information is

program-specific and can be located at

www.hnfs.com.


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:

•Thedateandtimeoftheevent

•Nameoftheprovider(s)and/orperson(s)

involved

•Locationoftheevent(address)

•Thenatureoftheconcernorcomplaint

•Detailsdescribingtheeventorissue

•Anyappropriatesupportingdocuments

Submit an HNFS PPN Grievance Form or a

letter outlining the grievance information

Fax 1-888-244-4025

Email [email protected]

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: Program-

specific guidelines dictate whether a service

decision or determination is appealable

and by whom. Refer to the dispute/appeal

requirements for the programs applicable

mailto:[email protected]?subject=HNFS%20PPN:%20Provider%20Inquiry

https://www.hnfs.com/content/hnfs/home/va/home/provider/preferred-provider-network-forms/grievances.html#form_1376595707024

https://www.hnfs.com/content/hnfs/home/va/home/provider/preferred-provider-network-forms/grievances.html#form_1376595707024


to you. Disputes/appeals regarding claims

or prior authorizations and referrals must

be submitted through the program-specific

appeals process.

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.

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:

•Thedisputemustincludetheprovider’s

name, identification (ID) number, contact

information, including telephone number,

and the original claim number.

•Ifthedisputeisregardingaclaimor

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.

•Ifthedisputeisnotaboutaclaim,the

provider must include a clear explanation

of the reason for the dispute, including if

applicable, relevant references to the PPA.

A provider dispute submitted on behalf of a

beneficiary is considered a beneficiary appeal

and is processed through the beneficiary

appeal process.

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.


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:



Fax: 1-888-244-4025

Email:

[email protected]

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 ManagementUtilization 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 ManagementThe 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


Net conducts case management activities on

covered services subject to benefit program

requirements.

Clinical Quality ManagementHealth 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.

Discharge PlanningAs 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.

Policy on Separation of Medical Decisions and Financial ConcernsHealth Net has a strict policy:

•UMdecisionsarebasedonmedicalnecessity

and medical appropriateness

•HealthNetdoesnotcompensatephysicians

or nurse reviewers for denials

•HealthNetdoesnotofferincentivesto

encourage coverage or service denial

•Specialconcernandattentionshouldbepaid

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 non-

network 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.


Rights and ResponsibilitiesBeneficiary Rights and ResponsibilitiesHealth 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–Beneficiarieshavethe

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–Beneficiarieshavetheright

to access emergency health care services when

and where the need arises.

Participate in treatment–Beneficiarieshave

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–Beneficiarieshave

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–Beneficiarieshave

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–Beneficiarieshavethe

responsibility to be knowledgeable about

benefit program requirements and options.

PPN program beneficiaries also have the

responsibility to:

•Showrespectforotherpatientsandhealth

care workers


•Makeagood-faithefforttomeetfinancial

obligations

•Usethedisputedclaimsprocesswhenthere

is a disagreement

•Reportwrongdoingandfraudto

appropriate resources or legal authorities

•Paycopayments,coinsuranceand

deductibles

•Payfornon-coveredservices(ifthe

beneficiary agreed in advance and in writing

to pay for these services)

•Payallchargesifineligibleforprogram

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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Index

Abuse .......................................................6, 7, 8

Address Change .............................................. 5

Appeal ................................................18, 21, 22

Balance Billing .............................................. 15

Beneficiary Identification (ID) Card ............. 9

Beneficiary Rights and Responsibilities ...... 25

CAQH ....................................................... 5, 10

Case Management ........................................ 23

Claims Adjudication .................................... 15

Claims Adjustment ...................................... 16

Claims Procedures ....................................... 15

Clinical Information Submission ................ 20

Clinical Quality Management ..................... 24

Coding Edits ................................................. 16

Comments ...................................................... 4

Conditions of Participation ......................... 10

Contact Us ...................................................... 6

Covered Services ............................................ 9

Credentialing ............................................ 3, 10

Delegation .................................................... 12

Discharge Planning ...................................... 23

Dispute Submission ..................................... 22

Electronic Claims Submission ..................... 15

Fee Schedule ................................................. 18

Fraud .................................................6,7, 19, 26

Good Cause for Delay Guidelines ............... 17

Grievance ...................................................... 21

Health Net Federal Services, LLC .................. 3

Health Net Products ...................................... 4

Health Net Program Integrity Department ..... 7

Health Net, Inc. .............................................. 3

www.hnfs.com ................................................ 5

Liability Insurance ....................................... 10

Medical Records ........................................... 19

Non-Covered Services ................................. 16

Office Procedures ......................................... 19

Other Adjustments Guidelines .................... 17

PIF .................See Provider Information Form

PPN ...............See Preferred Provider Network

Preferred Provider Network .......................... 3

Prior Authorization ...................................... 14

Prompt Payment of Claims ......................... 15

Provider Demographics Update Form.......... 5

Provider Directory ......................................... 6

Provider Information Form .......................... 5

Provider Overpayments ............................... 18

Questions ........................................................ 4

Recredentialing ............................................. 10

Referrals ........................................................ 14

Reimbursement ............................................ 17

Requests for Review of Denied Claims ....... 15

Separation of Medical Decisions and Financial

Concerns ....................................................... 24

Termination without Cause ......................... 12

Timely Filing Criteria................................... 17

Updates ........................................................... 6

Utilization Management .............................. 23

VH0215x033 (02/15)

Preferred Provider Network Provider Manual

Documents

Transcript of Preferred Provider Network Provider Manual