Non-Contracting Provider Policies
Information for Non-participating Providers: California
The following policies and procedures apply to provider claims for services that are adjudicated by California Health & Wellness Plan, except where otherwise noted.
Continuity of Care Request Forms – for Members
Purpose: Beneficiaries who are transitioning from fee-for-service into a managed care plan have the right to request continuity of care, such as completion of care from current providers in accordance with the state law and the health plan contracts, with some exceptions. All managed care plan beneficiaries with pre-existing provider relationships who make a continuity of care request must be given the opportunity to request coverage of continued treatment for up to 12 months with the out-of-network provider.
The Continuity of Care Request form is located here.
California Health & Wellness Plan requires that providers confirm eligibility as close as possible to the date of the scheduled service. Due to ongoing changes in eligibility, the best practice is to confirm eligibility no more than one day prior to providing a prior-authorized service.
To verify eligibility, providers should call California Health & Wellness Plan Provider Services via our toll-free number at (877) 658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number). Follow the menu prompts to speak to a Provider Services Representative to verify eligibility before rendering services. Provider Services will need the member name or member's Medi-Cal ID to verify eligibility.
Claims Settlement and Dispute Resolution Mechanism
(AB 1455, SB 367 and SB 634)
This information pertains to claims for services rendered by providers to California Health & Wellness members. Note: where contract terms apply, not all of this information may be applicable to claims submitted by California Health & Wellness Plan participating providers.
Timely Filing of Claims
Providers must submit first time claims no later than the sixth month following the month of service. When California Health & Wellness Plan is the secondary payer, the claims must be received no later than one year after the month of service to permit the provider to obtain proof of payment, partial payment or non-liability of the carrier. Claims received outside of these timeframes will be denied for untimely submission.
A request for adjustment, corrected claim or reconsideration of an adjudicated claim must be received no later than 365 days following the date of payment or denial of the claim. If favorable resolution of a claim is not obtained, a grievance or complaint concerning the processing or payment of the claim may be filed.
California Health & Wellness Plan encourages all providers to submit claims electronically. Our Companion Guides for electronic billing are available. Paper submissions are subject to the same edits as electronic and web submissions.
Providers are encouraged to participate in California Health & Wellness Plan's Electronic Claims/Encounter Filing Program through Centene. California Health & Wellness Plan (through Centene) has the capability to receive an ANSI X12N 837 professional, institution or encounter transaction. In addition, California Health & Wellness Plan (through Centene) has the capability to generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). For more information on electronic filing, contact:
Providers who bill electronically are responsible for filing claims within the same filing deadlines as providers filing paper claims. Providers who bill electronically must monitor their error reports and evidence of payments to make certain all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters.
Important Steps to a Successful Submission of EDI Claims
- Select clearinghouse to utilize or California Health & Wellness Plan's website
- Contact the clearinghouse to inform them you wish to submit electronic claims to California Health & Wellness Plan
- Inquire with the clearinghouse regarding what data records are required
- Verify with Provider Services at California Health & Wellness Plan that the provider is set up in the California Health & Wellness Plan system before submitting EDI claims
- You will receive two reports from the clearinghouse
- ALWAYS review these reports daily. The first report will indicate the claims that were accepted by the clearinghouse and are being transmitted to California Health & Wellness Plan, as well as those claims not meeting the clearinghouse requirements. The second report will be a claim status report showing claims accepted and rejected by California November 2021 Provider Services 1-877-658-0305 Page 112
- For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number.
- Health & Wellness Plan. ALWAYS review the acceptance and claim status reports for rejected claims. If rejections are noted correct and resubmit.
- MOST importantly, all claims must be submitted with provider identifying numbers. See the companion guide for claim form instructions and claim forms for details.
NOTE: Provider identification number validation is not performed at the clearinghouse level. The clearinghouse will reject claims for provider information only if the fields are empty.
California Health & Wellness Plan only accepts the CMS 1500 (02/12) and CMS UB-04 paper claim forms. Other claim form types will be rejected and returned to the provider.
Professional providers and medical suppliers complete the CMS 1500 (02/12) form and institutional providers complete the CMS UB-04 claim form. California Health & Wellness Plan does not supply claim forms to providers. Providers should purchase these from a supplier of their choice. All paper claim forms must be on the original red and white version to facilitate clean acceptance and processing. Black forms will not be accepted. Paper claims must be typed or printed with size 10 or 12 Times New Roman font with NO HIGHLIGHTING, ITALICS, or BOLD text.
Please check to see that the text is aligned appropriately in order to avoid delays or errors in reading the information. Hand-written claims will not be accepted. Some claims may require additional attachments. To reduce document-imaging time, please refrain from utilizing staples when attaching multiple page documents. Be sure to include all supporting documentation when submitting your claim. All documents should be submitted in paper form as no form of electronic media is accepted and will be sent back to the provider. If you have questions regarding what type of form to complete, contact California Health & Wellness Plan Provider Services at (877) 658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number).
Submit claims to California Health & Wellness Plan at the following address:
California Health & Wellness Plan
Claim Processing Department
P. O. Box 4080
Farmington, MO 63640-3835
Complete Claim Definition
A complete claim is a claim, or portion of a claim that is submitted on a complete format adopted by the National Uniform Billing Committee and which includes attachments and supplemental information or documentation that provide reasonably relevant information or information necessary to determine payer liability.
IMPORTANT NOTE: We require that all facility claims be billed on the UB-04 form.
California Health & Wellness Plan uses the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual as the standard source for codes and code descriptions to be entered in the various form locators (FL).
Correct coding is key to submitting valid claims. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available.
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), is currently used to code diagnostic information on claims. Multiple entities publish ICD-10-CM manuals and the full ICD-10-CM is available for purchase from the AMA bookstore on the Internet.
Use Healthcare Common Procedure Coding System (HCPCS) Level I and II codes to indicate procedures on all claims, except for inpatient hospitals. ICD-10-CM codes are used for procedure coding on inpatient hospital Part A claims.
For all other uses, Level I Current Procedural Terminology (CPT-4) codes describe medical procedures and professional services. CPT is a numeric coding system maintained by the AMA. The CPT code book is available from the AMA bookstore on the Internet.
Claim Submission Instructions
Mandatory Items for Claims Submission
- All professional and institutional claims require the following mandatory items:
- Appropriate type of insurance coverage (box 1 of the CMS-1500).
- Billing provider tax identification number (TIN), address and phone number.
- Billing provider National Provider Identifier (NPI).
- Bill type (institutional) and/or place of service (professional).
- Original submission is indicated with a 1 in claim frequency box or resubmission code (box 22).
- Codes 7 and 8 should be used to indicate a corrected, void or replacement claim and must include the original claim ID.
- Patient name, Health Net identification (ID) number, address, sex, and date of birth must be included. If the subscriber is also the patient, only the subscriber data needs to be submitted. If different, then submit both subscriber and patient information.
- Other health insurance information and other payer payment, if applicable.
- Patient or subscriber medical release signature/authorization.
- Accept assignment (box 13 of the CMS-1500).
- Referring provider name and NPI.
- Check if lab work was performed outside the physician's office and indicate charges by the lab (box 20 on CMS-1500).
- Rendering/attending provider NPI (only if it differs from the billing provider) and authorized signature.
- Primary diagnosis code and all additional diagnosis codes (up to 12 for professional; up to 24 for institutional) with the proper ICD indicator (only ICD 10 codes are applicable for claims with dates of service on and after October 1, 2015).
- Diagnosis pointers are required on professional claims and up to four can be accepted per service line.
- Diagnosis codes, revenue codes, CPT, HCPCS, modifiers, or HIPPS codes that are current and active for the date of service. Claims with incomplete coding or having expired codes will be contested as invalid or incomplete claims.
- Authorization, if applicable, should be sent in the 2300 Loop, REF segment with a G1 qualifier for electronic claims (box 23 for CMS-1500 or box 63 for UB-04).
- Referral information, if applicable.
- Inpatient institutional claims must include admit date and hour and discharge hour (where appropriate), as well as any Present on Admission (POA) indicators, if applicable.
- Inpatient professional claims must include admit and discharge dates of hospitalization.
- Admission type code for inpatient claims.
- Admitting diagnosis required for inpatient claims.
- Outpatient claims must include a reason for visit.
- Statement from and through dates for inpatient.
- Service line date required for professional and outpatient procedures.
- National Drug Code (NDC) for drug claims as required.
- Universal product number (UPN) codes as required.
- Accommodation code is submitted in Value Code field with qualifier 24, if applicable.
- Share of cost is submitted in Value Code field with qualifier 23, if applicable.
- Charges for listed services and total charges for the claim.
- Days or units.
- Early Periodic Screening, Diagnosis, and Treatment (EPSDT)/family planning indicators (box 24 in CMS-1500).
- Name and address of service location.
This is not meant to be a fully inclusive list of claim form elements. Additional fields may be required, depending on the type of claim, line of business and/or state regulatory submission guidelines.
To avoid possible denial or delay in processing, the above information must be correct and complete.
The following providers must include additional information as outlined:
- Emergency services providers: The claim must include a legible emergency department report and any state-designated data requirements included in statutes or regulations.
- Dentists and other professionals providing dental services: The form and data set approved by the American Dental Association (ADA), Current Dental Terminology (CDT) codes and modifiers, and any state-designated data requirements included in statutes or regulations. When services are authorized as a medical benefit, the provider should indicate "medical necessity" on the claim form to ensure proper routing.
- Non-primary care providers: The first and last name of the referring physician and the referral number given by the referring physician or independent practice association (IPA) (include state license number if available). The only exceptions are anesthesia and assistant surgeon claims described in Specific Billing Requirements.
- On-call physicians: Where applicable, physicians who are on call for a primary care physician (PCP) do not require a referral. The name of the PCP should be noted on the claim in box 19 or 23 on the CMS-1500 claim form. For self-referrals the provider should indicate Self-Referred in box 17 of the CMS-1500.
- Providers not specified: A properly completed paper or electronic billing instrument submitted in accordance with California Health & Wellness Plan specifications and any state-designated data requirements included in statutes or regulations.
Claims Coding Practice
California Health & Wellness Plan uses code-auditing software to assist in improving accuracy and efficiency in claims processing, payment and reporting, as well as meeting HIPAA compliance regulations. The software will detect, correct, and document coding errors on provider claims prior to payment by analyzing CPT, HCPCS, modifier, and place of service codes. Claims billed in a manner that does not adhere to the standards of the code editing software or Medi-Cal guidelines will be denied.
The code editing software contains a comprehensive set of rules addressing coding inaccuracies such as unbundling, fragmentation, up-coding, duplication, invalid codes, and mutually exclusive procedures.
The software offers a wide variety of edits that are based on:
- American Medical Association (AMA) – the software utilizes the CPT Manuals, CPT Assistant, CPT Insider's View, the AMA web site, and other sources Centers for Medicare & Medicaid Services' (CMS) National Correct Coding Initiative (NCCI) includes column 1/column 2, mutually exclusive and outpatient code editor (OCE0 edits); In addition to using the AMA's CPT Manual, the NCCI coding policies are based on national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices
- Public-domain specialty society guidance (i.e., American College of Surgeons,
- American College of Radiology, American Academy of Orthopedic Surgeons)
- Clinical consultants who research, document, and provide edit recommendations based on the most common clinical scenario
- Nationally-recognized coding guidelines, the software has added flexibility to its rule engine to allow business rules that are unique to the needs of individual product lines
Specific Billing Requirements
The following are billing requirements for specific services and procedures.
- All Services: Prior authorizations are required for all non-contracting provider claims except in certain emergent situations. A request for authorization must be made via telephone at (877) 658-0305.
- 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:
- 911 referral
- Law enforcement or fire department involvement
- Mental health hold (5150/5350)
- Motor vehicle accident (MVA)
- PCP request/referral
- Ambulatory/outpatient surgery claim: If implantable devices are included on the claim, one of the following must be submitted for each implant billed on the claim form:
- Copy of the manufacturer's invoice; or
- Copy of the medical record's implant log
- 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 California Health & Wellness Plan is the secondary payer; the provider must submit the claim and a copy of the Explanation of Benefits (EOB) from the primary carrier to California Health & Wellness Plan for payment consideration.
- Drug testing – Dates of service on and after January 1, 2017: California Health & Wellness Plan follows the Centers for Medicare & Medicaid Services (CMS) coding guidelines for reporting drug testing procedures as outlined in the 2017 CMS Clinical Laboratory Fee Schedule (CLFS) Final Determinations document posted on the CMS website (CMS8). A maximum of one definitive test may be billed per week, and one presumptive test may be billed per day with a maximum of three per week.
- Presumptive drug testing codes 80305, 80306, and 80307
- Definitive drug testing codes G0480, G0481, G0482, and G0659
- 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.
Non-Hospital Substance Abuse Facilities (Residential Treatment, Intensive Outpatient, Partial Hospitalization Facilities)
- Bill on a UB-04 form
Consolidated Billing – All charges for the patient stay should be included on the same bill, this includes therapy, treatment and ancillary services. Do not split bills by type of service or submit separate bills for overlapping dates of service for a component of treatment, including substance abuse toxicology testing.
- Type of bill – Enter the appropriate three- or four-digit code that indicates the type of bill you are submitting. The type of bill code used must correspond to the facility, Medicare certification and state license held by the billing entity.
- Revenue code – Enter the appropriate four-digit code that identifies the specific accommodation and specific ancillary services billed. Bills should use revenue codes to indicate the accommodation code and the specific therapy and ancillary services provided on each date of service. For outpatient programs, there must be date specific and, line item specific detail on the bill, meaning, that each therapy service on each date of service must be documented with the appropriate revenue code. Additionally, revenue codes used should correspond to the facility Medicare Certification and state license.
- Procedure code – Enter the appropriate HCPCS procedure code. All claims must specify the corresponding ancillary or therapy service provided to the patient on each day of service. This should include the number of units provided on each date of service
- Itemization – There must be a single line item date of service for every revenue code on all bills. If a particular service is rendered five times during the billing period, the revenue code and HCPCS code must be entered five times, once for each service date. The provider's billed charges for each component of the claim should be listed separately, for example, the charges must identify the accommodation charges (where applicable) and the charge for each therapy.
- Non-covered services – These must be identified using revenue code 099X. Include a description of the non-covered service and the corresponding charge for that service. Non-covered services include, peer-led groups, such as AA meetings, and other items, such as massage therapy, surfing, gym, or exercise activities, and luxury facility items, such as fine linens, hot tubs, whirl pool bath tubs, and private rooms.
- Vaccines for Children Program Billing Procedures
Participating providers must submit claims to California Health & Wellness for Vaccines for Children (VFC) program-supplied immunizations to receive reimbursement for the administration of the immunization administration CPT code and the associated VFC vaccine CPT code when requesting payment for the administration fee of VFC vaccines.
For each immunization administered, the claim must include:
- Vaccine CPT code with the modifier SL (indicating a state-supplied vaccine)
- Usual and customary charge
- Administration CPT code with modifier SL
Providers billing electronically must submit administration and vaccine codes on one claim form. Multiple claims should not be submitted.
Providers submitting multiple CMS-1500 successor forms must staple the completed forms together and number the pages appropriately.
Although the provider is receiving the vaccines from the VFC program, providers are reimbursed an administration fee per dose on claims submitted to California Health & Wellness Plan.
Use of modifier SL sufficiently identifies the claim as a state-supplied vaccine for which the billed vaccine charge is not reimbursed. Using modifier SL ensures that the claim is processed, the provider is reimbursed for the administration fee and the vaccination is included in performance measurements.
These billing procedures are designed to standardize billing practices and eliminate erroneous payments for state-supplied vaccines, which necessitate collection of overpayments from providers. Health Net may seek reimbursement of amounts that were paid inappropriately.
Failure to bill VFC claims in accordance with the billing procedures noted above results in denials for both the vaccine and the associated administration.
For all questions, contact California Health & Wellness Plan at 877-658-0305.
Acknowledgement of Claims
California Health & Wellness Plan acknowledges electronically submitted claims, whether or not the claims are complete, within two business days via a 277CA to the clearinghouse following receipt. Health Net acknowledges paper claims within 15 business days following receipt. If a paper claim is paid or denied within 15 days, the Remittance Advice (RA) is the acknowledgment of claims receipt. A provider may obtain an acknowledgment of claim receipt by calling the Provider Services Center at 877-658-0305.
Claims received from a provider's clearinghouse are acknowledged directly to the clearinghouse in the same manner and time frames noted above.
Reimbursement of Claims
California Health & Wellness Plan reimburses each complete claim, or portion thereof, from a provider of service no later than 45 business days.
This time frame begins after receipt of the claim unless the claim is contested or denied. California Health & Wellness Plan reserves the right to adjudicate claims using reasonable payment policies and non-standard coding methodologies. These policies and methodologies are consistent with available standards accepted by nationally recognized medical organizations, federal regulatory bodies and major credentialing organizations.
Hospitals submitting inpatient acute care claims for California Health & Wellness members:
- California Health & Wellness Plan uses an All Patient Refined Diagnosis Related Groups (APR DRG) pricing methodology that is consistent with Department of Health Care Services (DHCS) implemented Version 29 of APR DRG pricer.
- California Health & Wellness Plan is aware that some hospitals may submit inpatient claims with anticipated APR DRG code and anticipated reimbursement on a claim form; however, California Health & Wellness Plan reserves the right to assign the APR DRG for pricing and payment.
Denied or Contested Claims
California Health & Wellness Plan notifies the provider of service in writing of a denied or contested claim no later than 45 business days after receipt of the claim.
Date of contest or date of denial is the electronic mark or postmark date indicating the date when the contest or denial was transmitted electronically or mailed by U.S. mail.
A contested claim is one that California Health & Wellness Plan cannot adjudicate or accurately determine liability because more information is needed from either the provider, the claimant or a third party.
Incomplete claims or claims that require additional information are contested in writing by California Health & Wellness Plan in the form of an Explanation of Payment/Remittance Advice (EOP/RA), which may in some circumstances be followed by additional written communication within the timeframes noted above. If California Health & Wellness Plan needs additional information before the claim can be adjudicated, the necessary information must be submitted within 365 days of the date of the EOP/RA that reflects the contested claim, in order to have the claim considered by California Health & Wellness Plan.
The EOP/RA for each claim, if wholly or partially denied or contested, includes an explanation of why Health Net made its determination. Supplemental notices describing the missing information needed is sent to the provider within 24 hours of a determination to contest the claim.
Each EOP/RA includes instructions on how to submit the required information in order to complete the claim if California Health & Wellness Plan has contested it. Each EOP/RA reflecting a denied, adjusted or contested claim includes instructions on the department to contact for general inquiries or how to file a provider dispute, including the procedures for obtaining provider dispute forms and the mailing address for submission of the dispute.
Interest on Late Payment of Claims
Late payments on complete Medi-Cal claims that are neither contested nor denied automatically include interest at the rate of 15 percent per year for the period of time that the payment is late.
The late payment on a complete Medi-Cal claim for emergency room (ER) services that is neither contested nor denied automatically includes the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at 15 percent per year for the period of time that the payment is late.
If California Health & Wellness Plan does not automatically include the interest fee with a late-paid complete Medi-Cal claim, an additional $10 is sent to the provider of service.
Overpayment of Claims
The California Health & Wellness Plan Provider Services Department is available to assist with overpayment inquiries. A provider who has identified an overpayment should send a refund with supporting documentation to:
California Recoveries Address:
California Health & Wellness Overpayment Recovery Department
P.O. Box 886027
Los Angeles, CA 90088-6027
If California Health & Wellness Plan identifies an overpayment due to a processing error, coordination of benefits, subrogation, member eligibility, or other reasons, a notice is sent that includes the following:
- Member's name and ID number
- Provider's account number
- Date of service
- Amount of overpayment
- California Health & Wellness' payment date
- Detailed reason for the refund request
Failure to comply with timely filing guidelines when overpayment situations are the result of another carrier being responsible does not release the provider from liability.
If the overpayment request is not contested by the provider, and California Health & Wellness Plan does not receive a full refund or an agreed-upon satisfactory repayment amount within 45 days from the date of the overpayment notification, a withhold in the amount of the overpayment may be placed on future claim payments.
Whenever possible, California Health & Wellness Plan strives to informally resolve issues raised by providers at the time of the initial contact. If an issue cannot be resolved informally by a customer contact associate, California Health & Wellness offers its non-participating providers a dispute and appeal process.
To initiate a dispute, a provider should submit a Provider Dispute Resolution Form (PDF) in writing, within 365 days of the action precipitating the complaint, identifying the claims involved and specifically describing the disputed action or inaction regarding such claims.
- The documentation must also include a detailed description of the reason for the request.
- Unclear or non-descriptive requests could result in no change in the processing, a delay in the research or delay in the reprocessing of the claim.
- To submit a Provider Dispute Resolution Form for a claims issue:
- Mail the form to California Health & Wellness Plan at this address:
- California Health & Wellness Plan
ATTN: CLAIMS DISPUTES
P.O. Box 4080
Farmington, MO 63640-3835
- California Health & Wellness Plan
- A claim dispute should be used only when a provider has received an unsatisfactory response to a request for reconsideration.
We recommend that providers wishing to dispute a claim complete the Provider Dispute Resolution Form (PDF), which identifies required information that must be submitted with the dispute.
- To expedite processing of your dispute, please include all required information.
- Submission of a copy of your claim is not required unless you have a correction to make. In the case of a correction, please submit a corrected claim with your dispute.
- All documents should be submitted in paper form as no form of electronic media is accepted and will be sent back to the provider.
If the request for reconsideration results in an adjusted claim, the provider will receive a revised Explanation of Payment (EOP). If the original decision is upheld, the provider will receive a revised EOP or letter detailing the decision and steps for escalated reconsideration.
California Health & Wellness Plan will respond to disputes within 45 working days of receipt of the request for reconsideration.