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A CPT code will not be automatically changed to another CPT code reflecting a reduced intensity of the service when such CPT code is one among or across a series that includes, without limitation, codes that differentiate among simple, intermediate and complex, complete or limited and/or size.

A CPT code appended with a CPT modifier 59 will be recog- nized and separately eligible for payment to the extent that it designates a distinct or independent procedure performed on the same day by the same physician.

No CPT modifier 51 exempt CPT codes are subject to the multiple procedure reduction logic or rule.

Supervision and interpretation CPT codes are separately identifiable and eligible for payment.

“Add-on” codes, as designated by CPT, will be recognized and eligible for payment as separate codes and shall not be subject to the multiple procedure logic or rule.

Recommended vaccines and injectibles, as well as the admin- istration of these vaccines and injectibles, will be reimbursed.

No global period for surgical procedures will be longer than any period designated by the Centers for Medicare and Medicaid Services for such surgical procedures.

Disclosure of fee schedule information, claim coding and payment policies

Health Net will reference the applicable formula or database used to create its fee schedule and provide, either directly or through its Web site, a means to apply the formula or database to obtain rate information per CPT code.

Health Net will respond within 10 days to e-mailed inquiries requesting the fee-for-service dollar amount allowable for each CPT code for those CPT codes that a physician in the same specialty reasonably uses in providing covered services. Physicians are allowed up to two inquires per year.

Physicians can “opt-out” of products through which Health Net offers its provider network for use by entities other than Health Net, its affiliates or its self-funded plan customers.

Physicians will be given 90 days’ advance notice of all planned Material Adverse Changes to Health Net’s policies and procedures affecting performance under contracts with participating physicians.

“Payment in full” or other restrictive endorsement on a payment by Health Net is not binding and can be appealed.

Copies of contracts along with all attachments will be provided to physicians upon request within 30 days or as soon as practical.

Capitation fees will be paid retroactive to the date of enroll- ment, when a patient chooses a primary care physician (PCP) or is assigned to a PCP.

Health Net shall provide physicians who are paid on a capita- tion basis with monthly reports. These reports will include membership information to allow reconciliation of capitation payments.

Prompt payment requirements

Health Net is required to process and finalize payment for claims within 30 calendar days following the submission of all necessary information. Health Net is required to process and

finalize payment of claims within 15 business days following the submission of all necessary information for claims submitted electronically.

Interest will be paid at 6 percent on delayed claims.

Overpayment recovery

Overpayment recovery efforts will not be initiated more than 12 months after the original payment. A 30 day written notice will be provided to the physician prior to initiating an overpayment recovery effort (other than for recovery of duplicate payments).

Health Net will reimburse physicians for the reasonable cost of copying medical records that are required for the purpose of postpayment audit. No determination of recoupment, denial or overpayment recovery shall be based on extrapola- tion or statistical sampling.

Medically necessary or medical necessity definition

No retroactive retraction of a pre-certified medically neces- sary determination.

Health Net accepts the following definition of medical neces- sity for clinical conditions and mental health care, including treatment for psychiatric illness and substance abuse:

“Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and c) not primarily for the conven- ience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “gener- ally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, the views of physicians practicing in relevant clinical areas and any other relevant factors.


Arbitration fees for solo and small group physician practices are capped at $1,000.

New physician credentialing

New physician group members will be credentialed within 90 days of the receipt of the application. Physicians also can submit an application prior to their employment.

For additional information, visit the AMA Private Sector Advocacy (PSA) Web site at www.ama-assn.org/go/psa or call (800) 262-3211 and ask for PSA.


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