Appeals & Grievances

Appeals | Grievances | How to File

Many Issues or Concerns can be promptly resolved by our Customer Service Department. If you have not already done so, you may want to first contact Customer Service before submitting one of the forms below.

Appeals

An "appeal" is the type of complaint you make when you want us to re-evaluate and change a decision we have made about what benefits are covered for you or what we will pay for a benefit. You need to file your appeal within 60 calendar days from the date on the organization determination notice (denial letter) that you get from us. Health Net may accept an appeal or redetermination beyond 60 days if you show Health Net good cause for an extension.

To file a standard appeal, you must send a written request stating the nature of the complaint, giving dates, times, persons, places, etc. involved. Or you may complete the Medical Appeals & Grievance Department Request for Reconsideration form in place of a letter. Completion of this form is not required to file an appeal. Please include copies of any additional information that may be relevant to your appeal and mail, email or fax to the address(s) and/or fax number listed below.

How quickly we decide on your appeal depends on the type of appeal:

For a decision about payment for services you already received: After we receive your appeal, we have 60 calendar days to reconsider our decision. If we find in your favor, we must issue payment within 60 calendar days of the date of receipt of your appeal request.

For a standard decision about authorizing medical care: After we receive your appeal, we have up to 30 calendar days to make a decision, but will make it sooner if your health condition requires. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

For a decision about payment for Part D prescription drugs you already received: After we receive your appeal, we have 7 calendar days to make a decision. If we find in your favor, we have 30 days from the date of receipt of your appeal request to issue payment.

For a standard decision about Part D prescription drugs: After we receive your appeal, we have up to 7 calendar days to make a decision, but will make it sooner if your health condition requires.

In addition, you, any doctor, or your authorized representative can ask us to give you an expedited ("fast") reconsideration or appeal (rather than a "standard" appeal) about drugs or services that you have not already received, if you or your doctor believe that waiting for a standard appeal decision could seriously harm your health or your ability to function. If we give you an expedited ("fast") decision, we must make our reconsideration decision as expeditiously as your health condition might require, but no later than 72 hours of receiving your request. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. For an expedited ("fast") appeal, contact us by telephone or fax at the number listed below.

For denials of medical appeals: If we deny any part of your medical appeal, your case will automatically be forwarded to an independent review organization, to review your case. This independent review organization contracts with the Federal government and is not part of our Plan. You or your appointed representative should mail, email or fax your written appeal request to the address listed below.

The independent reviewer will review our decision. If any of the medical care or service you requested is still denied, you can appeal to an administrative law judge (ALJ) if the value of your appeal meets the minimum requirement. You will be notified of your appeal rights if this happens.

There is another special type of appeal that applies only when coverage will end for SNF (Skilled Nursing Facility), HHA (Home Health Agency) or CORF (Comprehensive Outpatient Rehabilitation Facilities) services. If you think your coverage is ending too soon, you can appeal directly and immediately to Health Services Advisory Group, which is the Quality Improvement Organization in the state of California.

  • If you get the notice 2 days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice.
  • If you get the notice and you have more than 2 days before your coverage ends, then you must make your request no later than noon of the day before the date that your Medicare coverage ends.

Important Pharmacy Appeals Information

If you have questions about these Appeal procedures you may refer to the applicable sections of the Evidence of Coverage (EOC) for your respective plan as outlined below, or you can call Health Net Customer Service at the phone number listed below.

Plan Name Appeals EOC Section
Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Healthy Heart Plan 1 (HMO), Health Net Healthy Heart Plan 2 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Ruby Plan 1, Health Net Seniority Plus Ruby Plan 2 (HMO),Health Net Jade (HMO SNP), Health Net Violet (PPO) Chapter 9, section 5 (Medical Care) & section 6 (Part D Prescription Drugs)
Health Net Seniority Plus Green (HMO) Chapter 7, section 5 (Medical Care)
Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP) Chapter 9, section 6 (Medical Care) & section 7 (Part D Prescription Drugs)

If you want to inquire about the status of an appeal, please call Health Net Customer Service at the phone number listed below.

Grievances

A grievance is any complaint other than one that involves an organization determination. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office. You need to file your grievance within 60 calendar days after the event. Please note: For a complaint about Part D prescription drugs, Health Net can give you more time if you have a good reason for missing the deadline.

The Appeals and Grievances department can only investigate complaints filed against our contracted providers.

If you have a grievance, we encourage you to first call Health Net Customer Service at the number listed below. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Grievance procedure. There is no form required for filing a grievance. You may also submit your complaint in writing or via facsimile or email to Health Net at the address and/or fax number listed below.

We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

You are also entitled to a quick review of your complaint if you disagree with our decision in the following scenarios:

  • If we deny your request for an expedited review of a request for medical care
  • If we deny your request for an expedited review of an appeal of denied services
  • If we decide an extension is needed to review your request for medical care
  • If we decide an extension is needed to review your appeal of denied medical care

You may also submit your request in writing or via facsimile or email to Health Net at the address and/or fax number listed below. We will quickly review your request and notify you of our decision as expeditiously as your health condition might require, but no later than 24 hours of receiving your complaint.

For quality of care complaints, you may also complain to the Quality Improvement Organization (QIO)

Complaints concerning the quality of care received under Medicare may be acted upon by Health Net under the grievance process, by an independent organization called the QIO, or by both. For example, if an enrollee believes he/she is being discharged from the hospital too soon, the enrollee may file a complaint with the QIO in addition to or in lieu of a complaint filed under Health Net's grievance process. For any complaint filed with the QIO, Health Net will cooperate with the QIO in resolving the complaint.

How to file a quality of care complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. An enrollee who files a quality of care grievance with a QIO is not required to file the grievance within a specific time period. Consult your Evidence of Coverage for specific contact information.

As a Health Net member, you have the right to request information on the following:

  • Additional information from Medicare by calling 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), which is the national Medicare help line, 24 hours a day, 7 days a week.
  • To obtain an aggregate number of Health Net's grievances, appeals and exceptions, please call Health Net Customer Service at the phone number listed below.

If you would like to appoint a representative to act on your behalf, please click here for additional information.

If you have questions about these Grievance procedures you may refer to the applicable sections of the Evidence of Coverage (EOC) for your respective plan as outlined below, or you can call Health Net Customer Service at the phone number listed below.

Plan Name Grievance EOC Section
Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Healthy Heart Plan 1 (HMO), Health Net Healthy Heart Plan 2 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Ruby Plan 1, Health Net Seniority Plus Ruby Plan 2 (HMO), Health Net Jade (HMO SNP), Health Net Violet (PPO) : Chapter 9, section 10
Health Net Seniority Plus Green (HMO): Chapter 7, section 9
Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP): Chapter 9, section 11

If you want to inquire about the status of a Grievance, please call Health Net Customer Service at the phone number listed below.

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Filing an Appeal or Grievance

You may file an appeal or grievance using the following methods:

By Calling our Customer Service Department

8:00 am – 8:00 pm, 7 days a week

Health Net Amber: 1-800-431-9007
Health Net Healthy Heart: 1-800-275-4737
Health Net Green: 1-800-275-4737
Health Net Ruby: 1-800-275-4737
Health Net Violet: 1-800-960-4638
Health Net Gold: 1-800-275-4737
Health Net Jade: 1-800-275-4737
TTY/TDD (all MA/MAPD plans): 1-800-929-9955

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.

For QIO Complaints, please contact:

Health Services Advisory Group (Quality Improvement Organization - QIO)

Phone: 1-800-841-1602
TDD/TTY: 1-800-881-5980
www.hsag.com

Health Services Advisory Group
700 N. Brand Blvd, Suite 370
Glendale, CA 91203

Online

Use this form when appealing the denial of a medical service, claim or copay/benefit. It will be submitted to the Appeals & Grievances Department for review and response back to you.

Use this form when appealing the denial of a prescription drug service or claim. It will be submitted to the Appeals & Grievances Department for review and response back to you.

Use this form to formally express your dissatisfaction with the care or service(s) you have received. It will be submitted to the Appeals & Grievances Department for review and response back to you.

By Mail or Fax

You may mail your appeal or grievance via a written letter or by using one of our Forms. Please mail or fax to:

Medical Services:
Health Net Appeals and Grievances Department
PO Box 10344
Van Nuys, CA 91410-0344
Fax: 1-877-713-6189

Prescription Drug Services:
Health Net Appeals and Grievances Department
PO Box 10450
Van Nuys, CA 91410-0450
Fax: 1-800-977-1959

Forms

Medical Services Forms

Request for Reconsideration Form

Prescription Drugs Forms

Redetermination Form

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