← Back to list
26-892 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
Effective date
Oct 1, 2026
Identified
Jul 22, 2026
Summary
Health Net California has implemented QMED 2.0 encounter data submission requirements for capitated PPGs and hospitals in Fresno, Kings, and Madera counties. Effective October 1, 2026, providers must 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), uniqueness (duplicate submissions below 0.5%), and reasonability (total denials below 2%). Failure to comply will result in negative performance reporting, plan-level non-compliance risk, and required corrective action.
Get alerts when payers change rules like this one
We check Health Net and other payers every day and email you when a change matches your specialty and state.
Get Health Net alertsPolicy Monitoring is free. No card required.
What to do
Action · 1 steps
01REQUIREMENTS:
Immediate Actions (Now through September 30, 2026):
- Billing team must audit all encounter submission processes to ensure compliance with QMED 2.0 standards
- Verify that 100% of submitted encounters include valid Type 1 (individual) rendering provider NPIs that match NPPES records and were active on date of service
- Implement system validations to prevent duplicate encounter submissions (target: <0.5% duplicate encounters; <5% duplicate service lines for institutional; <0.5% for professional)
- Establish denial management workflow to correct DHCS-denied encounters within 10 calendar days of denial notification
- Configure billing software to track and report: submission timeliness, denial rates, NPI validity, and duplicate submissions
- Train all billing and coding staff on common causes of denials: missing/invalid NPIs, use of Type 2 instead of Type 1 NPIs, invalid DRGs, missing/invalid NDCs, invalid bill types
- Create monitoring dashboard to track performance against all five QMED 2.0 measures
By October 1, 2026:
- Ensure at least 90% of all encounters are submitted and accepted within 90 days of date of service
- Ensure at least 97.5% of DHCS-denied encounters are corrected within 10 calendar days of denial
- Ensure at least 99.5% of DHCS-denied encounters are corrected within the reporting quarter
- Ensure at least 90% of encounter service lines include valid Type 1 rendering provider NPI
- Maintain duplicate encounters below 0.5% and duplicate service lines below specified thresholds
- Maintain total DHCS denied encounters below 2%
Ongoing (Quarterly):
- Billing team must review QMED 2.0 performance reports provided by Health Net
- Take immediate corrective action on any identified compliance gaps
- Resubmit all corrected encounters within the reporting quarter
Consequences of Non-Compliance:
- Negative impact to provider performance reporting
- Increased risk of plan-level non-compliance
- Required remediation and corrective action
- Performance monitoring and escalation by Health Net
Applies to: Participating Physician Groups (PPGs) and Capitated Hospitals in Fresno, Kings, and Madera counties billing to Medi-Cal through Health Net California
Original notice
26-892 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.