The subscriber number can be found on your Health Net Insurance card. Please enter the complete ID, including all letters and numbers. All letters must be typed as capital letters.
Policies & Procedures
According to Medicare guidelines, an appointed representative is a person who can act on your behalf to request an exception or appeal. This person can be a relative, friend, advocate, doctor, or anyone else whom you trust to act on your behalf. If you want to appoint someone to act for you, then both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Please note that your physician or other prescriber is not required to submit a signed Appointment of Representative (AOR) form CMS-1696 or other equivalent notice. Physicians and other prescribers may request a redetermination on your behalf at any time without completing an AOR form.
Send your statement to the following address:
Health Net Amber (HMO SNP), Health Net Green (HMO), Health Net Jade (HMO SNP), Health Net Ruby (HMO) and Health Net Ruby Select (HMO):
Appeals and Grievances Dept.
P.O. Box 279410
Sacramento, CA 95827
You can use the form that is attached at the bottom of this page or you can make your own statement (an equivalent written notice) as long as it contains all the required information.
The required information of an 'equivalent written notice' is one that:
If you need assistance in naming your appointed representative, you can call us at one of the numbers listed below.
Health Net Customer Service (8 a.m. - 8 p.m., 7 days a week)
|Health Net Amber (HMO SNP):||(800) 977-7522, TTY/TDD (800) 977-6757|
|Health Net Green (HMO):||(800) 977-7522, TTY/TDD (800) 977-6757|
|Health Net Jade (HMO SNP):||(800) 977-7522, TTY/TDD (800) 977-6757|
|Health Net Ruby (HMO) and
Health Net Ruby Select (HMO):
|(800) 977-7522, TTY/TDD (800) 977-6757|
|Prescription Drug Services||(800) 977-7522, TTY/TDD (800) 977-6757|
Calls received after hours will be handled by our automated phone system and a Health Net representative will call you back on the next business day.
Link to the Centers for Medicare and Medicaid Services (CMS) Appointment of Representative Form CMS-1696
Information last updated 04/15/2013