MedicaidAdministrativeMedium impact
20-020 Change to Capitated Claims Encounter Duplicate Logic
Health Net·CA·Reimbursement
Effective date
Nov 25, 2019
We identified it
Jun 20, 2026
Summary
Health Net changed duplicate claim detection logic for Medi-Cal capitated encounters to include NDC codes. Claims with the same procedure code and NDC code combination will now be rejected as duplicates, whereas previously only procedure codes were checked.
Action Required
Immediately: Billing team must ensure that when submitting multiple capitated encounter claims for the same patient on the same date with the same procedure code, each claim uses a unique NDC code. Update billing software validation rules to prevent duplicate procedure code + NDC code combinations. Review and resubmit any rejected encounters since November 25, 2019.