CommercialReimbursementHigh impact
23-346m Bill Correctly to Get Paid for Primary Diagnosis and Interim Claims Submitted
Health Net·CA·Reimbursement
Effective date
Jun 21, 2023
We identified it
Jun 20, 2026
Summary
Health Net will implement new claim edits effective June 21, 2023, that will deny claims with inappropriate primary diagnoses (including manifestation and sequela codes) and interim claims missing proper discharge status. Providers must submit corrected claims with compliant primary diagnosis codes following CMS and ICD-10 guidelines.
Action Required
By June 21, 2023: Billing team must update claim review processes to verify primary diagnosis codes comply with CMS and ICD-10 guidelines before submission. Avoid using manifestation codes, sequela codes, or circumstance codes as primary diagnoses. For interim claims, ensure bill types ending in XX2 or XX3 include discharge status 30. Train coding staff on acceptable primary diagnosis selection. Claims with non-compliant primary diagnoses will be denied.