ExchangeDocumentationHigh impact
25-545 New Claims Prepayment Review Policy Will Confirm if Documentation Supports Billed Charges
Health Net·CA·Reimbursement
Effective date
Aug 12, 2025
We identified it
Jun 20, 2026
Summary
Health Net will implement prepayment claim reviews using Optum's Comprehensive Payment Integrity tool for Marketplace HMO/PPO products starting August 12, 2025. Providers may receive requests for medical records and billing documents to support billed charges, and failure to submit requested documentation will result in technical denials until information is provided.
Action Required
Before August 12, 2025: Billing team must establish workflow to respond promptly to Health Net medical record requests for Marketplace HMO/PPO claims. Ensure all claims have complete provider orders and clinical documentation supporting diagnoses and services billed in medical records. Train staff on submission procedures when requests are received. Failure to submit requested documentation will result in technical claim denials.