MedicaidAdministrativeHigh impact
26-893 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
Health Net·CA·Reimbursement
Effective date
Oct 1, 2026
We identified it
Jul 22, 2026
Summary
Health Net California has implemented QMED 2.0 encounter submission standards for capitated PPGs and hospitals in Imperial County, Medi-Cal. Providers must now meet strict performance thresholds for timeliness (90% of encounters submitted within 90 days), accuracy (97.5% of denied encounters corrected within 10 days), completeness (90% with valid Type 1 rendering provider NPIs), and other quality measures, effective October 1, 2026. Failure to comply will result in negative performance reporting, Plan non-compliance, and corrective action.
Action Required
REQUIREMENTS:
By October 1, 2026: Billing team must implement the following encounter submission processes:
1. TIMELINESS - Ensure at least 90% of all encounters are submitted and accepted by Health Net within 90 days of date of service (DOS). Additionally, ensure at least 97.5% of DHCS-denied encounters are corrected and resubmitted within 10 calendar days of the denial notice (not the DHCS 15-day requirement).
2. ACCURACY - Monitor that at least 99.5% of DHCS-denied encounters are corrected within the reporting quarter. Billing team must review denial reports immediately upon receipt and prioritize correction within the 10-day window.
3. COMPLETENESS - Verify that at least 90% of encounter service lines include a valid Type 1 (individual) rendering provider NPI. Audit billing system to ensure Type 2 (organizational) NPIs are NOT being used for rendering/attending providers. Update encounter submission templates and validation rules to require Type 1 NPIs.
4. NPPES VALIDATION - Billing team must validate all submitted NPI data matches the NPI and qualifier in the 837 file and is active/valid on the date of service. Cross-reference against NPPES database before submission.
5. UNIQUENESS - Prevent duplicate encounters (keep below 0.5%) and duplicate service lines (keep below 5% for Institutional, 0.5% for Professional). Review billing practices and update system rules to eliminate duplicate submissions.
6. REASONABILITY - Keep total DHCS-denied encounters below 2% through quality review processes.
7. MONITORING - Establish a process to regularly monitor performance reports from Health Net and take immediate corrective action if any metric falls below threshold. Designate a billing staff member as QMED 2.0 compliance owner.
8. PROVIDER EDUCATION - Communicate requirements to all participating providers, particularly regarding Type 1 NPI requirements, timely correction of denials, and accurate billing practices (valid DRGs, NDCs, Bill Types).
CONSEQUENCES: Failure to meet QMED 2.0 requirements will result in negative provider performance reporting, increased Plan-level non-compliance risk, required corrective action monitoring, and potential escalation by Health Net.