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.
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 write a letter stating the nature of the complaint, giving dates, times, persons, places, etc. involved. Or you may complete the 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 send or fax to the address 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 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 a "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 a "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 a "fast" appeal, contact us by telephone or fax at the number listed below.
If you have questions about this procedure or if you want to inquire about the status of an appeal, please call Health Customer Service at the phone number listed below.
If we deny any part of your 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.
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, HHA or CORF 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.
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. Health Net can give you more time if you have a good reason for missing the deadline.
If you have a grievance, we encourage you to first call 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 to Health Net at the address 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:
You may also submit your request in writing or via facsimile to Health Net. 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.
If you have questions about this procedure or if you want to inquire about the status of a grievance, please call Health Net Customer Service at the phone number listed below.
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.
Health Net of Arizona
MA Appeals and Grievances Department
1230 W. Washington St., Ste. 401
Tempe, AZ 85281-1245
Health Net Customer Service (8 am - 8 pm, 7 days a week)
Health Net Amber: 1-800-977-7522 Health Net Jade: 1-800-977-7522 Health Net Green: 1-800-977-7522 Health Net Ruby: 1-800-977-7522 TTY/TDD (all MA/MAPD plans): 1-800-977-6757 Fax (all MA/MAPD plans): 1-800-805-1542 Health Net Orange: 1-800-806-8811 TTY/TDD (Orange) 1-800-929-9955 Fax (Orange): 1-800-977-1959
Physicians should call: 1-800-548-5524.
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.
Health Services Advisory Group (Quality Improvement Organization - QIO)
Medical Services Forms
Important Appeals Information
Information last updated 09/03/2010