Interest on Late Payment of Claims
The late payment on a complete HMO, POS, AIM, Healthy Families Program, or 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.
Late payments on all other complete HMO, POS, AIM, and Healthy Families Program 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.
If Health Net does not automatically include the interest fee with a late-paid complete HMO, POS, AIM, Healthy Families Program, or Medi-Cal claim, an additional $10 is sent to the provider of service.
The late payment on a complete PPO, EPO or Flex Net claim for ER services that is neither contested nor denied automatically includes the greater of $15 per year or interest at the rate of 10 percent per year beginning with the first calendar day after the 30-working-day period.
Late payments on all other complete PPO, EPO or Flex Net claims that are neither contested nor denied automatically include interest at the rate of 10 percent per year beginning with the first calendar day after the 30-working-day period subject to exceptions pursuant to applicable state law including fraud, misrepresentation, eligibility determinations, or instances in which the carrier has not been granted reasonable access to information under a provider’s control.
If Health Net fails to notify the provider of service in writing of a denied or contested claim, or portion thereof, and ultimately pays the claim in whole or in part, computation of the interest begins on the first calendar day after the applicable time period for denying or contesting claims has expired.
Overpayment of Claims
If Health Net determines that an overpayment has occurred, Health Net notifies the provider of service in writing within 365 days of the date of payment on the overpaid claim through a separate notice that includes the following information:
• Member name
• Claim ID number
• Date of service
• Clear explanation of why Health Net believes the claim was overpaid
• The amount of overpayment, including interest and penalties
The 365-day time period does not apply to overpayments caused in whole or in part by fraud or misrepresentation on the part of the provider.
The provider of service has 30 working days to submit a written dispute to Health Net if the provider does not believe an overpayment has occurred. In this case, Health Net treats the claim overpayment issue as a provider dispute.
If the provider does not dispute the overpayment, the provider of service must reimburse Health Net within 30 working days from the receipt of Health Net’s notice or, as permitted by law, interest begins to accrue at the rate of 10 percent per year beginning with the first day after the 30-working-day period.
Health Net may recoup uncontested overpayments by offsetting overpayments from payments for a provider’s current claims for services as permitted under the Fair Claims Settlement Practices Regulations (in section 2695.11 of title 10, of the California Code of Regulations (CCR)).
A written notification is sent to the provider of service if an overpayment is recouped through offsets to claim payments. The notification identifies the specific overpayment and the claim ID number.
