Provider Dispute Resolution Process for California
Note: Participating providers, log in to access the Provider Library to find procedures specific to your network participation agreement. The following information is provided for non-participating providers:
Definition of a Provider Dispute
A provider dispute is a written notice from the non-participating provider to Health Net that:
- Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested
- Challenges a request for reimbursement for an overpayment of a claim
- Seeks resolution of a billing determination or other contractual dispute
Provider Dispute Time Frame
Health Net accepts disputes from providers if they are submitted within 365 days of receipt of Health Net's decision (for example, Health Net's Remittance Advice (RA) indicating a claim was denied or adjusted), except as described below. If the provider does not receive a claim determination from Health Net, a dispute concerning the claim must be submitted within 365 days after the statutory time frame applicable to Health Net for contesting or denying the claim has expired.
Submission of Provider Disputes
When submitting a provider dispute, a provider should use a Provider Dispute Resolution Request form. If the dispute is for multiple, substantially similar claims, complete the spreadsheet on page 2 of the Provider Dispute Resolution Request Form.
|Line of Business||Provider Dispute Resolution Request Form|
|Commercial IFP||Request form (PDF)|
|All other Commercial and Medi-Cal||Request form (PDF)|
The provider dispute must include the provider's name, ID number, contact information including telephone number, and the same number assigned to the original claim. Additional information required includes:
- If the dispute is regarding a claim or a request for reimbursement of an overpayment of a claim, the dispute must include a clear identification of the disputed item, the date of service, and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect.
- If the dispute is not about a claim, a clear explanation of the issue and the basis of the provider's position.
A provider dispute that is submitted on behalf of a member is processed through the member appeal process. When a provider submits a dispute on behalf of a member, the provider is considered to be assisting the member with his or her member appeal.
If the provider dispute involves a member, the dispute must include the member's name, ID number, a clear explanation of the disputed item, the date of service, billed and paid amounts, and the provider's position.
All provider disputes and supporting information must be submitted to:
|Line of Business||Address|
|Commercial||Health Net Commercial Appeals
P.O. Box 9040
Farmington MO 63640-9040
|Medi-Cal||Health Net Medi-Cal Appeals
P.O. Box 989881
West Sacramento, CA 95798-9881
If the provider dispute does not include the required submission elements as outlined above, the dispute is returned to the provider along with a written statement requesting the missing information necessary to resolve the dispute. The provider must resubmit an amended dispute along with the missing information within the time frame for dispute submissions and the amended dispute must include the information requested and required to make the dispute complete.
Health Net does not request that providers resubmit claim information or supporting documentation that was previously submitted to Health Net as part of the claims adjudication process unless Health Net returned the information to the provider.
Health Net does not discriminate or retaliate against a provider due to a provider's use of the provider dispute process.
Acknowledgment of Provider Disputes
Health Net acknowledges receipt of each provider dispute, regardless of whether or not the dispute is complete, within 15 business days of receipt.
Resolution Time Frame
Health Net resolves each provider dispute within 45 business days following receipt of the dispute, and provides the provider with a written determination stating the reasons for determination.
Past Due Payments
If the provider dispute involves a claim and it is determined to be in favor of the provider, Health Net pays any outstanding money due, including any required interest or penalties, within five business days of the decision. Accrual of the interest and penalties, when applicable, commences on the day following the date by which the claim should have been processed.
Dispute Resolution Costs
A provider dispute is processed without charge to the provider; however, Health Net has no obligation to reimburse the provider for any costs incurred during the provider dispute process.