Claims for Covered Services

Through Covered California™ for individuals and families, Health Net of California, Inc. offers Ambetter HMO and Ambetter PPO plans.

All of these plans come with a specific doctor network. There is no coverage for out-of-network services on Ambetter HMO plans, with the exception of urgent care, emergency care or pre-approved services; members must use the network that comes with these plans for all covered services. Ambetter PPO plans do cover out-of-network services but usually at a higher out-of-pocket cost to you.

When you use in-network services, your doctor (or other provider) sends the claim to Health Net. There is no paperwork for you! Just remember to keep your Explanation of Benefits (EOB) for your records.

Explanation of Benefits (EOBs)

An EOB is not a bill. It is a brief description of the benefits that apply to the services you received. It also shows details about services you received; like the amount your provider billed Health Net of California, Inc., the amount Health Net paid and the portion of charges for services that may be your responsibility. EOBs are sent after Health Net receives and processes claims.

Submitting a claim for reimbursement

In some situations, you may have to submit a claim for reimbursement if you get urgent care services or emergency care services, or other out-of-network covered services. To do that, please follow the steps outlined below.

Medical claims

1. Download and complete one claim form for each reimbursement request.
   • Medical claim form – English (PDF)
   • Medical claim form – En Español (Spanish) (PDF)
   Note: Claims must be submitted within 365 days of service.
2. Mail your claim to:
   Health Net Commercial
   PO BOX 9040
   Farmington MO 63640-9040

Balance Billing

Balance billing happens when doctors bill you for the difference between the charges they billed and the amount covered by your health plan. Members on Ambetter PPO plans may be balance billed for out-of-network services.

Doctors who are part of your plan's network cannot balance bill you. If you get services outside of your plan's network that comes with your plan, the doctor may bill you. However, non-emergency services provided by an Out-of-Network Provider at an in-network facility, and Out-of-Network emergency services and air ambulance services are payable at the Preferred Provider level of coverage, with the same cost-sharing and Deductible, if applicable, and without balance billing; the cost-sharing and Deductible will be calculated towards your Out-of-Pocket Maximum. On Ambetter HMO plans, Health Net will not cover any part of the bill for out-of-network services unless it was for urgent care services or emergency services, or pre-approved the out-of-network services. You will have to pay the full amount for any non-covered services.

Coverage with more than one health plan

Health Net will coordinate the benefits for members covered by two or more health plans to make sure claims are paid correctly. This is called coordination of benefits (COB).

Paying Individual plan premiums

You can pay your premium (or your bill) several ways. Your premium is the amount of money you pay each month for your health coverage. To avoid the risk of losing coverage, make sure you pay your premium before the first day of every month. Use one of the following options:

1. Online (our recommendation!). Log in to your member account at MyHealthnetCA to:
   • Choose online monthly bill payment by following the "pay online" instructions.
   • Enroll in automatic bill pay using your prepaid debit card, bank account or credit card. After your auto bill pay account is set up, all future premiums will be charged to that card or account.
   • Pay your premium (or your bill) without logging in*
   * This is a good option for paying your first premium, or when you want a direct link to our payment system.
2. Mail:
   • Send a check, cashier's check or money order to the address below. Make your check, cashier's check or money order payable to "Health Net" and remember to write your policy number on your check, cashier's check or money order.
   • Health Net CA Individual
   • P.O Box 748705
   • Los Angeles, CA 90074-8705
3. Phone:
   • Call us at 1-800-539-4193 and use our Interactive Voice Response (IVR) system. It's quick and available 24/7!
   • You can also call 1-888-926-4988 (TTY/TDD 711) between 8:00 a.m. and 5:00 p.m. PT to make your payment.
4. MoneyGram^®:
   • Find a MoneyGram location near you or call 1-800-926-9400.
   • Remember to bring:
     • Cash for your premium payment. Health Net will pay your MoneyGram transaction fee!
     • Your Health Net member ID number
     • Receive Code: 16375
     • Fill out the blue MoneyGram ExpressPayment^® form and use the MoneyGram phone or kiosk to complete your payment.
   • Ask a store associate if you need any help in making your payment.
   Learn more about making your Health Net invoice payment using MoneyGram

Grace Period

A grace period is the time we add to allow you to make your premium payment after the due date without causing a gap in coverage. The length of the grace period depends on which plan you are enrolled in.

30-day grace period

Enrolled members who do not receive federal premium tax credits and/or state premium assistance subsidies will receive a 30-day grace period.

Once the plan contract is effectuated, you have a 30-day grace period after your premium due date to pay your premium payment in order to avoid coverage terminated for nonpayment of premiums. The grace period begins the first day after the last day of paid coverage.

• Health Net will continue to provide coverage during your grace period.
• You will continue to be responsible for paying the outstanding premiums, copayments, coinsurance, or deductible amounts required under the plan contract for this period.

Your health coverage will be terminated for nonpayment of premiums if Health Net does not receive the total outstanding premium amounts due through the grace period. The total is due by the last day of the grace period.

90-day grace period for members who get premium tax credits

Enrolled members who receive federal premium tax credits and/or state premium assistance subsidies will receive a grace period of three consecutive months (90-days).

Once the plan contract is effectuated you have a 90-day grace period after your premium due date to pay your premium payment in order to avoid having your coverage terminated for nonpayment of premiums. The grace period begins the first day after the last day of paid coverage.

• Health Net will continue to provide coverage during your grace period. However, claims may not be processed for covered services provided to you during the second and thirds months of the grace period until your full premium is paid. Health Net will notify you and your providers about the nonpayment of premiums and the possibility of denied claims when you are in your grace period.
• You will continue to be responsible for paying the outstanding premiums, copayments, coinsurance, or deductible amounts required under the plan contract for this period.
• Your health coverage will be terminated for nonpayment of premiums if Health Net does not receive the total outstanding premium amounts due through the grace period. The total is due by the last day of the grace period. If this happens, the termination date of your coverage will be the last day of the first month of the three-month grace period.

Denied claims

Under certain conditions, we may reprocess a claim for denial after it was paid. You will then be responsible for payment. This is called a retroactive denial. Examples include, but are not limited to:

• You were not eligible for coverage at the time of service.
• The service was not a covered plan benefit.
• An approval was needed and not received before the services were given.
• You received non-emergent, non-urgent, non-approved out-of-network services on a plan that does not have an out-of-network benefit tier.

You can help avoid retroactive denials by:

• Paying your premium payments on time.
• Checking if your provider is in your plan’s network.
• Knowing your plan benefits, including which benefits need approval before services are given.

Recoupment of overpayments

Enrollee recoupment of overpayments is the refund of a premium overpayment to the member due to over-billing by Health Net. If an active member believes they overpaid their premiums, the member should contact the Customer Contact Center.

Medical necessity

Medical necessity is used to describe care that is reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care.

Prior authorization

For some types of care you or your provider will need to ask Health Net for permission before you get the care. This is called asking for prior authorization or prior certification (pre-approval). Health Net uses pre-approval to review a request to assess medical necessity of a covered benefit before you receive the benefit.

• The purpose of the review is to determine if your benefits apply, the requested service is beneficial, if it is needed medically, and if the treatment proposed is appropriate, for the level of care, length of stay, or place of service.
• Health Net maintains a list of drugs, devices, procedures, and other medical services that require pre-approval.
• Health Net will make a determination for routine pre-approvals within 5 working days of receiving all the information needed to make the decision. For requests in which a provider indicates or Health Net determines that the service is urgent or to be expedited, Health Net will make a determination as quickly as your health condition requires and no later than 72 hours after receiving the request.
• In the event of being admitted into a Hospital following outpatient emergency room or Urgent Care center services for Emergency Care; please notify Health Net of the inpatient admission within 24 hours, or as soon as reasonably possible.
• Health Net does not reward or offer financial incentives to reviewers to deny coverage or services.

On an Ambetter HMO plan, your Provider or Physician Group will authorize and coordinate all your care, providing you with medical services or supplies. You are completely financially responsible for medical care that the contracting Provider or Physician Group does not coordinate or authorize except for urgent care, emergency care or pre-approved services.

On an Ambetter PPO plan, a non-authorization penalty will apply to covered expenses that are subject to an authorization requirement if prior authorization is not obtained.

Prescription drugs

The list of drugs we cover is called the Health Net Essential Rx Drug List (PDF).

• For medications not on the list:
  • You can ask your doctor to prescribe one that is on the list.
  • Or, your doctor can call us to ask for an approval of a covered drug not on the list. These are called non-formulary drugs.
  • Health Net will make a coverage decision no later than 72 hours after receiving the request and any needed medical record.
• If you have a condition that might threaten your life, health or ability to function normally if not treated right away (exigency), or if you are currently getting treatment using a drug that is not on the Essential Rx Drug list, and not continuing the drug would create an urgent (exigent) circumstance, then you, your designee or your doctor can ask for an expedited review.
  • Health Net will make an expedited coverage decision within 24 hours after receiving the request and requested medical record.
• To request a refund for prescription drugs:

If you have paid out-of-pocket for a drug, you may be eligible for reimbursement. Please contact Customer Service for questions about reimbursements.

Customer Service

If you have questions about your Health Net plan call Customer Service: