Understanding Claims

When you see your doctor for a service, your doctor will ask to bill your insurance. That bill comes to Health Net as a claim. Your doctor has a specific amount of time to submit the claim. The timeframe can vary depending on if the doctor is contracted or not contracted with Health Net. Another phrase for this is in-network or out-of-network.

To learn more about claims, view Life of a Claim (PDF).

Vendor Claims

Depending on the type of service you receive, your doctor may send their claim to one of our vendors instead of directly to Health Net. These types of services include: 

  • Dental
  • Vision
  • Alternative care (such as chiropractic or acupuncture)
  • Behavioral health

If you have questions, contact the vendor that processes those claims directly. Not sure who to call? Don’t worry! Our Customer Contact Center can transfer you to the correct vendor. 

Claim Reimbursement Form

If you are submitting bills to request reimbursement for covered services, fill out the Medical Claim Reimbursement Form (PDF). Please answer each question completely. Attach fully itemized bills and proof of payment.

Understanding Your Explanation of Benefits (EOB)

Once your doctor submits a claim, you will get a statement. This statement is called an Explanation of Benefits (EOB). The EOB breaks down what the doctor charged, what Health Net allowed, and what you may owe the doctor. It is important to note that this is not a bill. It is a statement of what happened when you went to the doctor and what Health Net agreed to pay. 

To learn more about EOBs, view Understanding Your Explanation of Benefits (PDF).

Receiving Bills from Providers

Your provider may charge you for your copay at the time of the visit. You can check your benefit materials for information about your copays. After your provider sends the claim to Health Net, you may receive a bill if you owe money for amounts that are patient responsibility. This could be amounts that apply to your deductible or out-of-pocket maximum.

Why am I receiving a bill from my doctor before I receive the EOB from Health Net?

Doctor’s offices often call Health Net before your procedure or visit to learn what your plan pays for. This helps providers know what they might charge you based on your benefits and Health Net’s allowed amounts. When you get your EOB, review it to make sure the doctor’s office charged you the right amount. If you have questions about your bill, call your doctor’s office. If you have questions about understanding your EOB, call the Health Net Customer Contact Center.

Why am I being billed for more than what Health Net allowed?

If you went to a provider that is out-of-network with Health Net, the provider may bill you for any charges that Health Net did not pay. Always check ahead of time to make sure a provider you plan to see is in network to avoid any balance billing. Any amounts paid outside of the allowed amount (balance billed totals) will not apply to your out-of-pocket maximum.