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.
You can ask us for a coverage redetermination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then 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-1969 or other equivalent notice because a physician or other prescriber may request a redetermination on your behalf without completing an AOR form.
This statement must be sent to us at:
Health Net Orange (PDP)
Health Net Appeals and Grievances Dept.
P.O. Box 10450
Van Nuys, CA 91410-0450
You can use the form that is attached below or you can make your own statement as long as it contains all the required information.
If you need more help to name your appointed representative, you can call us at:
Health Net Orange (PDP): (8 am - 8 pm, 7 days a week)
Link to the Centers for Medicare and Medicaid Services (CMS) Appointment of Representative Form CMS-1696
Information last updated 08/20/2012