Billing requirments and claim filing tips - Healthnet

 Healthnet - Information for Non-participating Providers


Specific Billing Requirements:

•    Allergy injections:
Specify type of injections provided in Box 24D of the CMS-1500 form.
•    Ambulance claim: Trip reports are not needed for the following claims:
o    911 referral
o    Law enforcement or fire department involvement
o    Mental health hold (5150/5350)
o    Motor vehicle accident (MVA)
o    PCP request/referral

•    Anesthesia claim:

Include surgeon's name and license number instead of the referring physician's name. For a Cesarean section performed after epidural anesthesia, indicate administration time for the general anesthetic and the epidural separately on the claim. The unit field should contain the number of time units (not minutes) being charged. Do not include base value or modifier units.

•    Antigen injections:
Specify the type of antigen given by using appropriate HCPCS code. Antigens are reimbursed separately.

•    Assistant surgeon:

Include surgeon's name in Box 17 of the CMS-1500. Use modifier -80 after CPT code for a physician. Use modifier -AS after CPT code for non-physician.

•    Coordination of benefits (COB):
When Health Net is the secondary payor; the provider must submit the claim and a copy of the Explanation of Medical Benefits/Explanation of Benefits (EOMB/EOB) from the primary carrier to Health Net for payment consideration.

•    Eye exams:
Claims for exams related to diseases or injuries of the eye must include diagnosis.

•    Injectable medications:
When billing for injectable medications, list appropriate HCPCS code identifying medication name, NDC number, strength, dosage, and method of administration.

•    Itemized OB care:
State reason why a global maternity fee is not being billed.

•    Lab collection fee:
A collection and handling fee may only be billed for laboratory work sent to an outside laboratory. The name of outside laboratory and tests performed must be entered on claim form
.
•    Multiple diagnoses:
Indicate specific diagnosis for each procedure billed.

•    Sigmoidoscopy:
Claims must include the length of the exam in centimeters. If the exam is over 35 centimeters, include modifier -22 (no report is required).

•    Trauma:
When billing a claim or itemization that is stamped trauma or with revenue code 208, an emergency room (ER) and Trauma Team Activation sheet/report must be attached to the claim.

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