HealthNet-National (Commercial and Medicaid) - Quick Reference, What You Need to Know...

Search Options

• As before, this payer supports three search options. However, some search options and criteria have changed.
  Now, this payer supports the following search options.

1. Subscriber ID.
2. Subscriber ID, Social Security Number, and Date of Birth.
3. Social Security Number, Last Name, First Name, and Date of Birth.

• For successful transaction processing, dependent data may be promoted to the subscriber loop.
   
• The prefix from a Member’s ID card should be entered with the Subscriber ID number. Entering only
  the Subscriber ID number may result in an error.
   
• This combines Health Net Medi-Cal (Commercial), Health Net California, Health Net Oregon,
  Health Net Arizona, and Health Net of the Northeast (Connecticut, New Jersey, and New York).
  This includes HMO, PPO, POS, and Medicare HMO. This also replaces Health Net Medi-Cal (Medicaid).

Dates

• This payer uses both begin and end dates for an inquiry.
• This payer supports up to one year in the past. Future dates up to the end of the current month
  are allowed and there are no restrictions on date spans.
   
• Inquiry dates now reference the Plan Date – 291 (DTP01).
• The 5010 response returns the Eligibility Date – 307 (DTP01).
  Specifically, the Eligibility Date is returned in both the 2100C and 2110C loops.

Response Data

Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.

• By default, the inquiry uses a generic “Health Benefit Plan Coverage – 30” service type.
  This payer also supports service types: 1, 30, 33, 35, 38, 50, 86, 88, and 98.
   

• The 5010 response does not return subscriber relationship information (2100C, INS01, and INS02).
  Specifically, the INS01=Y (Insured is Subscriber) and INS02=18 (Self) is not returned.
   

• The 5010 response now uses service type codes for Physician Office Visit Sick – BY,
  Physician Office Visit Well – BZ, Mental Health – MH, and Urgent Care – UC.
   

• This payer has stopped using the “U” designation for In Plan and Out of Plan Network (EB12=U).
  Now, they extensively use a “W” for both In Plan and Out of Plan Network (EB12=W).
   

• When applicable, the response now returns service type codes for hospital services. Specifically,
  Hospital Room and Board – 49, Hospital Emergency Accident – 51, Hospital Emergency Medical – 52,
  and Hospital Ambulatory Surgical – 53 are now returned.
   

• The 5010 response now provides the PCP's Last Name and First Name. (2120C, NM103, and NM104).
  Previously, both the First and Last Name was combined and returned in the NM103 segment.
   

• The response now returns the Independent Physicians Association (IPA) information with the
  correct qualifier (NM102=I3). Previously, it was returned as a Plan Sponsor (NM102=P5).
  Note, the Plan Sponsor is still returned and identified with the correct qualifier (NM102=P5).
   

• For Group Name and Group Number, the response now uses name segments (NM1) instead of
  reference segments (REF). Specifically, the Group Qualifier (NM102=GW), the Group Name (NM103),
  and the Group Number (NM109) are now returned in the 2120C loop. Previously, the response used the
  reference segment (REF01=6P and REF02) for Group information.