Electronic Data Interchange (EDI)

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For successful EDI claim submission, you'll need to use electronic reporting made available by your vendor and/or clearinghouse. View our payer ID numbers for more information. Health Net returns claims acknowledgements back to the clearinghouse with notifications of acceptance or rejections of individual claims. Providers can review these reports to check the status of their submission.

Health Net processes anesthesia, medical, coordination of benefits (COB), hospital, and surgical claims electronically. We accept claims directly from Change Healthcare, MD-OnLine/Ability, Availity and more. Claims regarding other benefits, including certain mental health, complementary treatments, pharmacy, and outpatient radiology are administered for Health Net by outside vendors and claims are processed by each vendor accordingly.

Our partnership with MD On-line/Ability allows even the smallest practice to take advantage of EDI savings, for free. Using this web-based solution, you can submit direct to Health Net on-line.

Submit claims directly to Health Net (through MD Online) 

In partnership with MD On-Line/Ability Network, Health Net now gives providers the option of exclusively submitting Health Net claims for free through a private label website that links directly from www.healthnet.com. The two products offered on the site allow providers to submit claims using either their own practice management software or direct data entry. The latter allows smaller practices to take advantage of the benefits of submitting claims electronically without having to bear the expense of specialized software. Providers may also use MD On-Line's services as an all payer solution for which standard MD On-Line fees apply.

• MD ON-LINE

If you're just starting out, we'll walk you through the process. Contact one of Health Net's EDI experts for more information.

Health Net's EDI specialists... on call for you 
Whether you're signing up for EDI, giving it another try or working to increase your electronic claim volume, EDI specialists are just a phone call away.

Effective January 1, 2018, for questions on electronic claims or electronic remittance advice for Individual Family Plan (IFP), Medicare Advantage (MA) HMO and MA PPO member claims with dates of service (DOS) on or after January 1, 2018, contact:

Centene EDI Department 
1-800-225-2573, extension 6075525 
Or by email at: EDIBA@centene.com

The following providers can continue to contact Health Net EDI department by email at edi.support@healthnet.com:

• Oregon EPO, POS, PPO, CommunityCare

The following are some pointers about claims submissions, the HIPAA glossary of EDI terms and frequently asked questions (FAQs).

Here are some tips from our EDI specialists for successful claims submission:

Providers in Oregon and Washington

• Submit claims with the patient's name and birth date exactly as it appears on their Health Net ID card.
• Health Net processes medical, hospital, anesthesia, surgical, and emergency room (ER) claims electronically from both participating and nonparticipating providers.
• Health Net encourages the electronic submission of all claims, including COB claims; however supporting documentation may be requested for the following types of claims: StopLoss, trauma and newborn NICU claims.
• Avoid timely filing issues by understanding and regularly monitoring EDI reports from your vendor/clearinghouse. Always ensure that the claim was not only just sent but that it was also accepted by the payer. This will improve your turnaround for rejected claims to ensure they are reviewed and resubmitted in a timely manner.

Q: CAN CLAIMS BE PAID FASTER IF I SUBMIT THEM ELECTRONICALLY?

Yes. Electronic claims are generally received in less time than those sent via the mail. Thus, processing time is often reduced.

Q: ARE THERE COSTS ASSOCIATED WITH ELECTRONIC CLAIMS SUBMISSION THROUGH A CLEARINGHOUSE?

There are many options for electronic claim submission. Depending on the needs of your organization, there may be costs associated. Clearinghouses should be contacted directly so needs and options can be discussed.

In partnership with MD On-Line, Health Net now gives providers the option of exclusively submitting Health Net claims for free through a private label website that links directly from www.healthnet.com. The two products offered on the site allow providers to submit claims using either their own practice management software or direct data entry. The latter allows smaller practices to take advantage of the benefits of submitting claims electronically without having to bear the expense of specialized software. Providers may also use MD On-Line's services as an all payer solution for which standard MD On-Line fees apply.

Q: WHAT ARE THE ADVANTAGES OF SUBMITTING MY CLAIMS THROUGH A CLEARINGHOUSE?

Submitting through a clearinghouse has many advantages including:

• It is not necessary to test with Health Net. Clearinghouses are HIPAA compliant.
• Payer reports are submitted electronically through the clearinghouse vs. being sent via mail.
• Clearinghouses will make available to providers the initial acceptance report confirming receipt of your claims by your clearinghouse and the payer. Payer Acceptance/Rejection reports can be used as proof of timely filing.
• Initial Acceptance Report: This report shows your clearinghouse accepted the EDI claim and forwarded it to Health Net for additional payer editing and processing. Please note that claims can pass clearinghouse edits but still be rejected by Health Net.
• Health Net Reject Report: This report shows that Health Net rejected the claim for "invalid subscriber ID number." Please note that a claim that is filed and "rejected" is not considered "received" by Health Net. These claims should be corrected and resubmitted electronically as soon as possible to avoid timely filing issues.
• Clearinghouses will notify providers of updates on changes in Health Net's electronic claim submission policies.

Q: WHAT IF I AM USING A VENDOR/CLEARINGHOUSE THAT IS NOT ON YOUR LIST?

Many vendors/clearinghouses have agreements for transmitting EDI claims through other clearinghouses. Please contact your vendor/clearinghouse and verify connectivity to Health Net.

Q: CAN NONPARTICIPATING PROVIDERS SUBMIT CLAIMS ELECTRONICALLY?

Yes. All claims can be submitted electronically from both participating and nonparticipating providers. Get started here.

HIPAA Standard 270/271 Eligibility Transactions

Requests for eligibility status for a single commercial, Medicare or state health programs member transaction may be submitted by registered participating providers on the Health Net provider website. Select the appropriate Verify Eligibility link under Eligibility & Benefits to the left to get started.

To request eligibility and obtain eligibility information for multiple members at one time, providers can use the 270/271 eligibility transaction through one of two electronic clearinghouses. A 270 request provides eligibility verification information directly to providers through a real-time link. Providers submit a request for a single HIPAA standard 270 or multiple 270s and obtain the 271 responses from Health Net online.

271 responses are also compliant with the Council for Affordable Quality Healthcare (CAQH^®)/Committee on Operating Rules for Information Exchange (CORETM) Phase II requirements.

In accordance with the Health Insurance Portability and Accountability Act (HIPAA) privacy requirements for submission of electronic health care transactions, Health Net is compliant in meeting and adopting the 270/271 eligibility transaction standards as outlined by HIPAA and with the Administration Simplication Operating rules for eligibility and health care claim status transactions. Check with your vendor/clearinghouse for sending/receiving eligibility requests using the 270/271 real time transaction or contact one of the Health Net clearinghouses listed below to set up the HIPAA standard 270 request:

To comply with the requirements of the U.S. Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Disproportionate Share Hospital Program (DSH), the Managed Risk Medical Insurance Board (MRMIB), and the National Committee for Quality Assurance (NCQA), Health Net requires information about use of health services by its members.

Capitated participating physician groups (PPGs), hospitals and ancillary providers are required to provide complete encounter data about professional services rendered to Health Net members. These services include office visits, X-rays, laboratory tests, surgical procedures, anesthesia, physician visits to the hospital, inpatient, outpatient, emergency room, out-of-area, or skilled nursing facility (SNF) services, and all professional referral services. Capitated participating facilities (and PPGs with dual-risk contracts) are required to provide encounter data monthly about institutionally based services rendered to Health Net members.

Encounter data submissions must include all member-paid cost share amounts, such as copayments, coinsurance and deductibles applicable to the member’s benefit. In addition, any rejected encounter data must be corrected and resubmitted in order for complete information and correct member-paid cost share amounts to be captured and accumulated. Encounter data submission is also an integral part of the Health Net Quality of Care Improvement Program (QCIP) (applicable only for HMO and Point of Service (POS) products) and Healthcare Effectiveness Data and Information Set (HEDIS^®)*. Refer to the Quality Improvement (QI) topic for more information on QCIP.

Reporting of encounter data is extremely important. Health Net and its affiliated health plans are required to provide encounter data to regulatory agencies. The following procedures are required for encounter reporting:

• Reporting of services must be on a per member, per visit basis, rather than a monthly summary. An accounting of all services rendered by date and member must be submitted to Health Net or Molina Healthcare, depending on the member’s health plan affiliation. The encounter data should be submitted via electronic transmission in the H ANSI 837 5010 X12 format through the encounter clearinghouse, TransUnion. Encounter records must include the same data elements as would be required on a fee-for-service (FFS) claim form.
• Health Net does not accept encounter and encounter summary reports on paper or directly from capitated PPGs. Providers should forward electronic encounters only. For additional information about how to submit encounters electronically, refer to 837 5010 Professional and Institutional Standards (pdf), 837 Institutional Companion Guide (pdf) and 837 Professional Companion Guide (pdf).
• All encounter reporting must identify members by their Health Net identification numbers. This number is on each member’s identification card. Submission of encounter data without the member identification number is not acceptable and is returned for correction.

Contact the Enc_Team@healthnet.com for assistance in developing or modifying procedures to accomplish complete encounter data submission.

*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).