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File Appeals & Grievances

File an Appeal or Grievance

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.

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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 coverage determination/organization determination notice (denial letter) you received. 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 in the How to File section 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 (for medical appeals) 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 in the How to File section 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.

For denials of Part D appeals: If we deny any part of your Part D appeal, you or your appointed representative can mail or fax your written appeal request to the independent review organization to the address and / or fax number listed below:

MAXIMUS Federal Services
3750 Monroe Ave., Suite #703
Pittsford, NY 14534-1302

Toll-free fax number for enrollees: 1-866-825-9507
Fax number for enrollees: (585) 425-5301

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 Livanta, which is the Quality Improvement Organization in the state of California. See "How to File" section below to contact Livanta.

  • 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 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 in the How to File section below.

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

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/TDD Hearing Impaired 1-877-486-2048), which is the national Medicare help line, 24 hours a day, 7 days a week.
  • To obtain a total number of Health Net's grievances, appeals and exceptions, please call Health Net Customer Service at the phone number listed in the How to File section below.

Appointing a Representative


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

Grievances

A grievance is any complaint or dispute other than an organization determination, expressing dissatisfaction with the manner in which Health Net Medicare Programs provides health care services. 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, 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 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 in the How to File section 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 for 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 (expedited grievance) 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 or a Part D drug
  • If we deny your request for an expedited review of an appeal for denied services or a Part D drug
  • 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 expedited grievance request orally, in writing or via facsimile or email to Health Net at the address and/or fax number listed in the How to File section 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.

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 in the How to File section below.

If you want to inquire about the status of a grievance, please call Health Net Customer Service at the phone number listed in the How to File section below.

As a Health Net member, you have the right to:

  • Tell Medicare about your complaint by calling 1-800-MEDICARE (1-800-633-4227; TTY/TDD Hearing Impaired 1-877-486-2048), which is the national Medicare help line, 24 hours a day, 7 days a week. Or you may fill out the Complaint Form available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx
  • Obtain a total number of Health Net's complaints, appeals and exceptions; please call Health Net Customer Service at the phone number listed in the How to File section 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 a member believes he/she is being discharged from the hospital too soon, the member 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. A member who files a quality of care grievance with a QIO is not required to file the grievance within a specific time period. Please see below in the 'How to File an Appeal or Grievance' section for specific contact information.


Appointing a Representative


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

How to File an Appeal or Grievance

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


  • Call our Customer Service Department

    February 15 - September 30 *
    Monday through Friday, 8:00 a.m. to 8:00 p.m.
    October 1 - February 14 **
    7 days a week, 8:00 a.m. to 8:00 p.m.

    * February 15 - September 30, calls on Saturdays, Sundays, and Federal holidays, with the exception of President’s Day, will be handled by our automated phone system.
    ** October 1 - February 14, calls on Thanksgiving and Christmas Day will be handled by our automated phone system.

    All Health Net Amber (HMO SNP) plans: 1-800-431-9007
    All Health Net Healthy Heart (HMO) plans: 1-800-275-4737
    All Health Net Green (HMO) plans: 1-800-275-4737
    Health Net Jade (HMO SNP): 1-800-431-9007
    All Health Net Ruby (HMO) plans: 1-800-275-4737
    Health Net Gold Select (HMO): 1-800-275-4737
    Health Net Violet (PPO): 1-800-960-4638
    Health Net Seniority Plus Sapphire and Sapphire Premier (HMO) plans: 1-800-275-4737
    TTY 711

    For Quality Improvement Organization (QIO) Complaints, please contact:

    Livanta
    BFCC-QIO Program
    9090 Junction Drive, Suite 10
    Annapolis Junction, MD 20701

    Toll-free Number: 1-877-588-1123
    TTY: 1-855-887-6668
    Appeals (Fax): 1-855-694-2929
    All other reviews (Fax): 1-844-420-6672
  • By Submitting an Online Form

    Go to the "Ready to File Online?" section below and select the appropriate Appeals or Grievances Online Form. Once submitted, it will be reviewed by the Appeals and Grievances Department and a response will be sent back to you shortly.

Ready to File Online?

Select the appropriate Appeals or Grievance Form below.

Use this form when appealing the denial of a medical service, claim, or copay/ benefit:
Medical Appeal Form

Use this form when appealing the denial of a prescription drug service or claim:
Prescription Drug Appeal Form

Use this form to express your dissatisfaction with the care or service(s) you have received:
Grievance Form

Once submitted, it will be reviewed by the Appeals and Grievances Department and a response will be sent to you shortly.


Information last updated 01-17-2017

Appointing a Representative

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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