For services covered by the No Surprises Act: If you are an out-of-network provider, the allowed amount is based on the recognized amount using the methodology outlined in the interim final rules of the Consolidated Appropriations Act (i.e., lesser of billed charges and the Qualifying Payment Amount).  For emergency services and non-emergency services, the member’s cost share is calculated against the recognized amount, and for air ambulance services, the member cost share is calculated against the lesser of the Qualifying Payment Amount or the billed amount.

Should you disagree with this payment amount, you may have the right to initiate a 30-business-day open negotiation period.  Any such request must be initiated within 30 business days from the date of this notice.  The negotiation period is for purposes of determining the out-of-network rate for covered services.  If the federal dispute resolution process is available to you and the out-of-network rate is not mutually agreed to during the open negotiation period, you have the right to initiate the Independent Dispute Resolution process within 4 business days after the end of the open negotiation period.

You may initiate your request for negotiation by submitting the Open Negotiation Notice (PDF) to us or contact us via secure/encrypted email at:

MHNNOSURPRISE@healthnet.com

or call us at: 844-966-0298 option 3

 

• The red ink we require allows our scanners to create a "cleaner" image of claims which is easier and faster to process with data capture automation software and increases our accuracy and timeliness of claims adjudication.
• MHN cannot accept non-standard claim forms or photocopied claims forms because those do not allow our scanners to create the clean image necessary to complete claim adjudication.
• If you receive a rejection from MHN for this reason, you will be given details on the requirements and the need to resubmit.
• Alternately, you can submit claims electronically to avoid this requirement.

As a facility offering Intensive Outpatient or Partial Hospitalization Program services (IOP/PHP) you may have received notice of the need to submit itemized details for the services provided and billed. You do not need to submit a dispute or appeal to provide MHN the additional information; just re-submit the claim – The additional information needed is: a breakdown of all services rendered, the costs, and all CPT or HCPCS codes.

Please review MHN’s policy regarding revenue codes for out-of-network facilities billing for IOP/PHP services below:

• Substance Use Disorder IOP/PHP Revenue codes 905, 906, 910-913 are not payable codes for out-of-network facilities. The only payable revenue codes are 043X, 0900, 0904, 0914-0916, 0918 and 0942.
• Mental Health IOP/PHP Revenue codes 905, 912 and 913 are the only payable revenue codes for out-of-network facilities.

If you are a contracted provider and received an overpayment /recoupment letter, please refund MHN as requested or else the funds owed may be offset against future payments.  Please do not request an offset of the overpayment because the offset process is automated. 

If you are a non-contracted provider and received an overpayment /recoupment letter, please refund MHN as requested. MHN will not offset the funds owed against future payments.

· BS

“This is not a denial. This is a request for a detailed itemized bill. This is not a request for medical records. Please resubmit an itemized, original UB04 claim form that: (a) provides details of the member's program for each date of service; (b) includes specific clinical services provided, including the revenue code and corresponding most specific HCPCS/CPT for each service; (c) contains the appropriate Type of Bill for the procedure rendered and (d) a breakdown of the services for each day; not the itemization of the higher level of care by date. The MHN website is available to you at www.mhn.com/providers/claims/claims-submission if you need billing assistance.”

What does this mean?:  It means that MHN needs more information to determine if the claim is payable. You do not need to submit a dispute or appeal to provide MHN the additional information; just re-submit the claim – The additional information needed is: a breakdown of all services rendered, the costs, and all CPT or HCPCS codes.

· IG

“Please resubmit claim with appropriate Type of Bill and/or Procedure/Revenue code combination for the services rendered. See www.mhn.com/provider/start.do for billing instructions.”

What does this mean?: It means that MHN needs the claim to be corrected to determine if the claim is payable. You do not need to submit a dispute or appeal to provide MHN the corrected claim; just re-submit the claim – The claim that you submitted has a Type of Bill and Procedure/Revenue code combination that doesn’t match.   Consider reviewing the authorization that you received from MHN to determine which Bill Type and Procedure/Rev Code combination is necessary. For example, if the authorization is for Mental Health services, the Bill Type should not indicate an SUD facility or location.

· DD

“Explanation of Medicare Benefit statement required.”

What does this mean?: It means that the member has Medicare coverage primary to MHN and MHN needs the EOB from the Medicare carrier to determine if the claim is payable (and how much).

What if the member has only Medicare Part A but MHN is asking for the Medicare EOB for outpatient services not covered by Medicare Part A?: The member can both complete and return the COB verification form sent to them by MHN –OR- Call MHN to provide the COB information verbally.

· EB

“Your claim has been received and it is being internally forwarded to the proper department within Health Net/Centene for processing. The original received date will be honored. All claims received are tracked to regulatory turnaround times and applicable interest payment guidelines.”

What does this mean?: It means that MHN received the claim but forwarded it to Health Net, California Health and Wellness, or Centene to process it under the medical benefit.

What if Health Net/California Health and Wellness/Centene is saying they haven’t received it? : If it has been more than 30 days, submit the claim directly to Health Net/California Health and Wellness/Centene – OR - call MHN to request a re-forwarding of the claim.

·  BC

“Not a covered benefit of the plan”

What does this mean?: It means that MHN has determined that the service is not covered, such as no out of network benefits, not covered services, or excluded diagnoses. If you disagree with MHN’s determination, you can submit an appeal or dispute and MHN will research and determine if the denial is accurate. 

· EG

“MHN is responsible for Behavioral Health Services only.”

What does this mean?:  It means that the claim you submitted was for services that are not considered Behavioral Health and therefore not MHN’s responsibility. Examples include, dental services, vision services, medical services, personal care items, or podiatry services. Additionally, Physical, Speech, and Occupational Therapy performed by a non-behavioral health provider is also not considered a behavioral health service.

· BB

“Member not eligible prior to effective date.”

What does this mean?:  It means that the date of service on the claim was before the member was eligible for coverage with us. Consider researching whether the member had coverage with another plan for the date of service. However, if you disagree with MHN’s determination, you can submit an appeal or dispute and MHN will research and determine if the denial is accurate.

· BR

“Please send a copy of the primary carrier's EOB”

What does this mean?:  It means that MHN believes the member has other coverage through another plan that is primarily responsible for the service you provided. Please resubmit your claim with the primary plan’s Explanation of Benefits (EOB). If the member does not have other coverage that is primarily responsible for the service you provided, please instruct the member to contact MHN to correct the information we have on file.

· TC

“Facility/provider not contracted for billed procedure.”

What does this mean?:  It means the service billed is not included in the contract with the facility or provider and therefore is not payable. If you disagree with MHN’s determination, you can submit an appeal or dispute and MHN will research and determine if the denial is accurate. If you want to add the service to your contract, please contact MHN Provider Relations at 1-844-966-0298 during standard business hours.

·  AE

“Actual visits exceed authorized visits”

What does this mean?:  It means the MHN approval does not cover the number of visits on the claim you billed. If you disagree with MHN’s determination, you can submit an appeal or dispute and MHN will research and determine if the denial of those additional visits is accurate.

· NP

“No out of network benefits available for service rendered”

What does this mean?:  It means the member does not have a policy with out of network benefits and is limited to services provided by a MHN contracted provider (unless it was an emergency). If you disagree with MHN’s determination, you can submit an appeal or dispute and MHN will research and determine if the denial is accurate.

· B2

“This is not a denial. Provider please resubmit claim with complete medical records for full length of stay including Initial Summary, Evaluations, Treatment Plan, Individual and Group Notes and Discharge Summary. MEDICAL RECORDS SUBMITTED SHOULD INCLUDE ALL APPLICABLE RELEASES OF INFORMATION. No action is required from the member at this time.”

What does this mean?:  It means the service (or services) has not be reviewed for medical necessity and MHN requires medical records to determine coverage.

· HF

“HCPC code not accepted by this administrator/payer”

What does this mean?:  It means that MHN does not accepted the HCPCS code under the plan your patient is enrolled.

·  VA, VB, VD, VE, VF, VG, VH, VI, VJ,  VK, VL, VM, VN,VO,VP, VQ,VR,VS, VT.VW, VY

What does this mean?:  It means that a code review was conducted on your claim. Please review the details in the remark code description to determine your next steps.  If you disagree with MHN’s determination, you can submit an appeal or dispute and MHN will research and determine if the adjudication is accurate.

No, practitioners may submit their claims electronically. However all paper claims for outpatient services must be submitted using the CMS (HCFA)-1500 (PDF).

Per California Assembly Bill 988, an out-of-network 988 center, mobile crisis team, or other provider of behavioral health crisis services shall not bill or collect an amount from the enrollee [or insured] for covered services except for the in-network cost-sharing amount.

The provider/facility must include 3 HIPAA identifiers for the member and 3 HIPAA identifiers for the provider/facility.

1. Member’s full name
2. Member’s date of birth
3. Member’s subscriber id
4. Provider/facility name
5. Provider/facility TIN
6. Provider/facility address (must be an address that MHN has on file)

• Clear your cache
• Remove the current bookmarked page
• Click the login link from MHN.com under “For Providers”
• Save that link as a favorite/bookmark,
  • right-click the link, select copy, then save that URL
• Log in as usual
• If the error persists please contact Provider Services at 844-966-0298 option 3

Our provider portal self-service enhancements offer you greater efficiency and the ability to manage more of your business with MHN through our Portal. With these enhancements, we're also asking you to select security questions which will allow you to perform these functions on your own. After you log in, you may be asked to set up new security questions.

Your account will remain active for 90 days (this is an increase from 60 days). If you do not log in to your account for more than 90 days, your account will become inactive, and you will need to unlock your account. Your account is also locked for security purposes when your password expires, or you attempt to access your account with an inaccurate password more than 4 times.

To unlock your account, please follow these simple steps:

• Enter your username and password.
• Click the "log-in" button.
• Click the "completing the online unlock process" link on the "Account Locked" page.
• On the subsequent page, answer the security question.
• Once the account is unlocked, please proceed to the Login page and enter your username and password to log-in to the site.
• After you log-in, the security information for your account may or may not need to be updated. Select a question from the list and provide the corresponding answer, if applicable.

• Enter your username and password.
• Click the "log-in" button.
• Click the "completing the online unlock process" link on the "Account Locked" page.
• On the subsequent page, answer the security question.
• Once the account is unlocked, please proceed to the Login page and enter your username and password to log-in to the site.
• After you log-in, the security information for your account may or may not need to be updated. Select a question from the list and provide the corresponding answer, if applicable.

• Click on the "forgot username" link
• Enter the required fields to retrieve your user name
• Answer the hint question to have your user name retrieved and sent to your e-mail address on file
• Enter the username in the email to access your account and proceed to the log-in page

• Click on the "forgot password" link located below the log-in box"
• Enter your username to retrieve your password
• Answer the hint question to have your password retrieved and sent to the email address on file for your web account
• Proceed to the Login page and enter the password in the email to access your account
• You will asked to change your password before continuing
• Click "Yes" on the "Security Alert" pop-up window
• Click the 'continue' button. You'll be accessing the site.

• Clear your cache
• Click on the "forgot password" link located below the log-in box"
• Enter your username to retrieve your password
• Answer the hint question to have your password retrieved and sent to the email address on file for your web account
• Proceed to the Login page and enter the password in the email to access your account
• You will asked to change your password before continuing
• Click "Yes" on the "Security Alert" pop-up window
• Click the 'continue' button. You'll be accessing the site.
• If still unable to reset your password please contact Provider Services at 844-966-0298 option 3

MHN's claim inquiry function is designed to give you up-to-date information on claims. The MHN provider portal provides member information up to 18 months from current date.  For claim information older than 18 months old please contact member services at 844-966-0298 Option 1. For MHN/Health Net/Centene employee (confidential) inquiries, please call (888) 327-0017.

• Go to the Internet browser address window and type in: www.providers.mhn.com
• The MHN website will appear
• At the MHN landing page, click on the Log In link on the top right-hand corner of the page
• Once logged in, review the options on the top of the screen
• Click on Claims and a drop-down box will appear
• Click on Claim Inquiry
• Put the provider’s NPI number in

                         o You can search from there and see all claims for the provider

• If you wish to limit your search to a specific member, enter the member’s id#  and hit Enter.  You will see all of the claims for that member and provider.
• If you wish to limit your search further, add additional information on this screen.
• Once you see the claim you want to review, click on the View Details link on the far right side of that line.
• You will see the details of the claim, including:

                        o Member information
                        o Subscriber information
                        o Claim details
                        o Claims status
                        o Diagnosis code(s)

• Each line of the claim will show

                        o Service date
                        o Receive date
                        o Place of service
                        o Procedure code
                        o Quantity of services
                        o Billed amount
                        o Allowed amount
                        o Paid amount
                        o Claim status
                        o A/R Code –is described under the Adjustment Reason section

• Clicking on the plus sign (+) next to each line on the claim will show you more details

                        o Member responsibility (copay, coinsurance, deductible)
                        o Payment total for the claim 
                        o Check information (date, check number, amount of check, and who and where the check was sent)

• Go back to the summary of claims by clicking Back to Summary on the bottom right
• Print the claims detail sheet by clicking Printer Friendly at the top right-hand corner

The MHN provider portal provides remittance advice information up to 6 months from the current date.  You will need the check number to search for this information. For remittance advice information older than 6 months old please contact member services at 844-966-0298 Option 1.

How To review and print a remittance advice (RA) on the MHN Provider portal:

• Go to the Internet browser address window and type in: www.providers.mhn.com
• The MHN website will appear
• At the MHN landing page, click on the Log In link on the top right-hand corner of the page
• Once logged in, review the options on the top of the screen
• Click on Claims and a drop-down box will appear
• Click on Remittance Advice Inquiry
  o   RAs for the last 6 months will show by date and check number
• Select the RAs that you wish to review
  o   Click on Display Selected RAs
• OR click on the date or check number of the single RA that you wish to review
• Print the RA by clicking Printer Friendly at the top right-hand corner
• Go back to the summary of RAs by clicking Back to Summary on the bottom right

Eligibility status is subject to change due to a variety of possible circumstances (i.e., termination of employment, elective change of benefit plan). Providers should assure that members have been informed to advise them of any changes in eligibility and should monitor member eligibility for benefits. The MHN provider portal provides member information up to 18 months from current date.  For facility based benefits or information prior to 18 months please contact member services at 844-966-0298 Option 4.  For MHN/Health Net/Centene employee (confidential) inquiries, please call (888) 327-0017.

MHN's claim inquiry function is designed to give you up-to-date information on claims. For EAP authorization information older than 18 months old please contact member services at 844-966-0298 Option 1. For MHN/Health Net/Centene employee (confidential) inquiries, please call (888) 327-0017.

• Go to the Internet browser address window and type in: www.providers.mhn.com
• The MHN website will appear
• At the MHN landing page, click on the Log In link on the top right hand corner of the page
• Once logged in, review the options on the top of the screen.
• Click on EAP Authorizations
• All EAP authorizations will show here

• After log-in, go to the "My Profile" menu
• Select the "Change email address" option

Using the Medi‐Cal Automated Eligibility Verification, you can find data by using the Automated Eligibility Verification System (AEVS) : 

• A state database that provides up‐to‐date information on a Medi‐Cal beneficiary’s eligibility.
• Assists in identifying from which managed care plan the member accesses their Medi‐Cal benefit.
• Provides eligibility for the past 12 months.

Click here for instructions in PDF format. Please review starting with Objective 1.

No. Practitioners may log in and submit these kinds of changes using the "Profile" section of this website. Practitioners may also contact Professional Relations department at MHN.ProviderServices@Healthnet.com to make changes to their practice information.

MHN contracts with the owner of the TIN. An individual contract represents the owner of the TIN, operating under their own name in a solo practice. Practitioners who are operating under a fictitious business name or share a TIN with other practitioners or entities must obtain a group contract with MHN.

Common reasons for termination of a practitioner's network participation are.

• Failure to adhere to contractual requirements.
• Inability or unwillingness to comply with MHN administrative requirements for network participation, including failure to comply with utilization management or credentialing procedures.

MHN does not terminate practitioner participation on grounds that the practitioner.

• Advocated on behalf of a member.
• Filed a complaint against MHN.
• Appealed a decision of MHN.
• Requested a review or challenged a termination decision.

Authorization information is sent to the address where the service (appointment) is to take place, unless the practitioner has notified Professional Relations that a particular address is not a mailing address. If the service address is not a mailing address, the authorization paperwork will be sent to the practitioner's primary address, as indicated on their practitioner application.

All other communications are sent to the practitioner's primary address, indicated on the application. To change your address, log in and use the "Profile" section of the website to submit changes. You may also contact Professional Relations at 844-966-0298, 8:00 AM-5:00 pm PST Monday through Friday.

Why am I not listed in your directory?

To be listed in our directory, practitioners must be contracted with MHN and available for patient referrals. Also, practitioners must have responded to our annual Data Integrity Project (DIP) or credentialing materials.