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Health Net implements additional claims review for certain ER visits

September 09, 2019
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 


Health Net recently notified physicians that effective July 1, 2019, it was implementing an additional claims review process for some emergency department facility and professional claims.

In Health Net’s June 14 Provider Update it states that when a claim is submitted for a Level 4 (99284) or Level 5 (99285) emergency department visit that includes a primary diagnosis generally associated with a low level of severity, the provider may receive a written request for medical records. The records request will identify it is from Health Net and Varis, the vendor the plan has engaged to conduct the medical records review.

Health Net has advised that once the records are received, they will be reviewed by certified coders and the claim will be paid at the level of service that is documented. If Health Net believes the documentation does not match the level of service billed and issues payment for a lower level code, the provider will receive a notice indicating the rationale for the down-coded payment. Physicians that disagree with the determination are encouraged to appeal in writing to Health Net.

The policy change applies to all Health Net lines of business, however separate notices were sent to physicians about the policy change for different product types.

According to the Health Net, the  policy (HNCA.PP.053) is intended to address an identified trend in upcoding by emergency room providers.

The California Medical Association (CMA) expressed concern that this policy will increase the administrative burden on physician practices and delay payment. In response, Health Net committed to ensuring reviews and determinations will be conducted within the timely payment timeframes, assuming the records are submitted timely. Additionally, Health Net has agreed to review the data by practice TIN every three months. Practices that achieve a 90% or higher coding accuracy threshold will be removed from the edit.

Practices with questions or concerns should contact Health Net at provider_services@healthnet.com. If your practice is experiencing voluminous requests for medical records or delays in payment as a result of this policy, contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmadocs.org

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