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26-891 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
Effective date
Oct 1, 2026
Identified
Jul 22, 2026
Summary
Health Net has implemented QMED 2.0 encounter data submission standards for capitated PPGs and hospitals, effective October 1, 2026. Billing teams must ensure 90% of encounters are submitted and accepted within 90 days of service, maintain 97.5% correction rate for denied encounters within 10 days, and meet strict accuracy, completeness, and duplicate thresholds or face performance penalties and corrective action.
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What to do
Action · 12 steps
01REQUIREMENTS:
- By September 30, 2026: Billing team must audit and update encounter submission processes to ensure 90% acceptance within 90 days of service date.
02Update billing system validation rules to require Type 1 (individual) rendering provider NPIs for at least 90% of service lines and validate NPIs against NPPES database for accuracy on date of service.
03- Immediately: Establish denial management workflow requiring correction of 97.5% of DHCS-denied encounters within 10 calendar days of denial date.
04Implement monitoring dashboard to track denial rates, duplicate submissions, and submission timeliness.
05- Before October 1, 2026: Billing team and providers must eliminate duplicate submission processes and implement controls to keep duplicates below 0.5% for encounters and 5% for institutional service lines (0.5% for professional).
06Review all billing practices and provider training protocols.
07- Ongoing (monthly): Billing team must monitor QMED 2.0 performance reports against five metrics: (1) timeliness—90% submitted/accepted within 90 days, (2) accuracy—99.5% of denied encounters corrected within quarter, (3) completeness—90% include Type 1 rendering NPI, (4) uniqueness—<0.5% duplicate encounters, <5% duplicate institutional service lines, <0.5% professional, (5) reasonability—<2% total DHCS denials.
08Resubmit all corrected encounters within the reporting quarter.
09- Immediate action required: Correct common errors including missing/invalid NPIs, use of Type 2 NPIs instead of Type 1, invalid DRGs, invalid/missing NDCs, and invalid/missing Bill Types.
10Validate all 837 file NPI data matches submitted NPI and qualifier.
11- Consequences: Failure to meet QMED 2.0 requirements will result in negative provider performance reporting, increased Plan-level non-compliance risk, and required remediation including performance monitoring and escalation.
12This affects Health Net capitated contracts in Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare, and Tuolumne counties.
Original notice
26-891 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.