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Claims Overview

You are not required to file any claims when you use an MHN network provider.

One of the greatest benefits of being an MHN behavioral health plan member is that you have access to our extensive network of over 23,000 providers. When you use an MHN network provider you get convenience, quality, superior service and lower out-of-pocket costs. Learn more about using a Network Provider.

Some MHN benefit plans cover services received from out-of-network providers; others do not. If your plan includes out-of network benefits, be sure to understand using out-of-network benefits before choosing a provider, as your out-of-pocket costs are almost always higher when you use an out-of-network provider. (For details about your benefits, including copayments, deduct­ibles and exclusions, please refer to your Certificate of Insurance or Summary Plan Description or contact MHN or your benefits manager.)

Click here to file an out-of-network claim or to make an inquiry about an existing claim.

Under certain circumstances, a claim may be denied after the member has received services from their provider. For example, Health Net/MHN may review the member's eligibility and Evidence of Coverage/Certificate of Insurance for plan benefits at the time the services were provided and find that the member was not eligible at the time of service. Another example is when an authorization was required and not obtained prior to the services being rendered.

Enrollees have the right to obtain refunds for over-applied deductibles, coinsurance, or co-pays. MHN pro-actively issues payments when a discrepancy is found; however, the Enrollee can call the Plan at (800) 444-4281 to initiate claim research or recoupment.

After a claim is processed by MHN, the enrollee (or dependent if over 18 years old) will receive an Explanation of Benefits (EOB) in the mail. Here is an explanation of some of the fields on the EOB:

  • DATE OF SERVICE – the date of service was rendered by the physician/provider or the date of admission for inpatient hospital stays.
  • CLAIM # – the number the health plan assigned to the claim.
  • CHARGES – the full amount billed by the physician/provider.
  • ALLOWED CHARGES – the maximum amount MHN will pay for a specific covered service.
  • NOT COVERED CHARGES – any portion of the charges that the member is responsible for paying including: services not covered under the Subscriber Contract, the difference between total changes and the usual and customary fee, or the penalty for failing to pre-certify on required services per the Subscriber Contract.
  • DEDUCTIBLE – the amount on this service that was applied to the member's yearly deductible.
  • COINSURANCE/COPAYMENT – the percentage and/or dollar amount that the member is responsible for according to the Subscriber Contract; coinsurance and co-payments are calculated based on the dollar amount remaining after other insurance and deductible are subtracted from the allowed charges.
  • PLAN PAYS – the amount remaining after other insurance, deductible, coinsurance and copayment amounts have been subtracted from the allowed charges. 
    Note: Based on assignment of benefit policy, the health plan may be required to pay the MHN nonparticipating physician/provider directly for allowed charges. The member should contact MHN directly with questions about any refund due.
  • MEMBER PAYS – the amount the member is responsible for paying to the physician/provider including the not covered, deductible, coinsurance, and co-payment amounts. Physician/provider cannot bill a Medicare member more than this amount.
  • REMARK CODES(S) – the remark code and its corresponding explanation (which can be found at the bottom of the statement) further explains payment or denial of this service.

MHN coordinates benefit payments with other insurance carriers when the enrollee is covered by multiple insurance. When the plan determined to be primary (per the Order of Benefit Determination) processes a claim, it does so without regard to any other insurance coverage. The secondary, tertiary, etc. plan will make supplemental payments resulting in a total payment of not more than the allowable expenses for the service provided.