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Medical Appeal Form

REQUEST FOR RECONSIDERATION (APPEAL) Part C

Your request for reconsideration (appeal) must be made within 60 calendar days from the date of the initial denial decision. If your request for reconsideration (appeal) is submitted beyond 60 calendar days, please submit an explanation why you were unable to make your request within this timeframe.

Health Net will make its reconsidered determination as expeditiously as your health requires, for Medicare and Medi-Cal covered services, we will give you a written decision within 30 calendar days after we get your appeal. For Medicare covered services(including services that are covered by both Medicare and Medi-Cal), a decision about payment for services and claim payment will be provided within 60 calendar days after we get your appeal. For Medi-Cal covered services, a decision about your payment for services and claim payment will be provided within 30 calendar days after we receive your appeal. We will make it sooner if your health requires. If we need more information to review your appeal for services you have not received, we may ask you for more time. You may ask us for more time for services you have not received (an extension) if you need to get more information to send to us. We will tell you if we are taking extra time and we will explain why we need more time.


Who May Make a Request

You (the enrollee), your provider or your representative can request an appeal. Representation documentation is required for appeal requests made by someone other than the Enrollee or the Enrollee's provider. Attach documentation showing the authority to represent the Enrollee (a completed Authorization of Representation Form CMS-1696 (pdf) or a written equivalent) if it was not already submitted at the coverage determination level. For more information on appointing a representative, contact our Customer Service Department.

(In addition, Cal MediConnect may also accept other forms of legal documentation)

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.

  • 1. Medicare Appeal Form
  • 2. Verification
  • 3. Confirmation
Appeals and Grievances Forms

Asterisk (*) items denote required fields.

ENROLLEE INFORMATION



REQUESTOR INFORMATION

Note: Complete the following section ONLY if the person making this request is not the Enrollee.

Important Note: Representation documentation is required for appeal requests made by someone other than the Enrollee or the Enrollee's provider. Attach documentation showing the authority to represent the Enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not already submitted at the coverage determination level. For more information on appointing a representative, contact our Customer Service Department


FIRST REQUEST FOR RECONSIDERATION


SECOND REQUEST FOR RECONSIDERATION

THIRD REQUEST FOR RECONSIDERATION

FOURTH REQUEST FOR RECONSIDERATION
Select a File to Attach

You can upload documents and attach them to your request.

How to Upload and Attach a Document

1. Get the document. Download a document such as the Authorization of Representation Form CMS-1696.

2. Scan the document. Using your home scanner or a scanner at a local copy store, scan your document and save it in a format we can accept: .doc, .pdf, .gif, .jpg or .bmp.

3. Upload the document. Click the 'Browse' button to find the document you want to upload. After you have uploaded one document, it will be automatically attached to your request. At that point, you'll have the option to upload additional documents. You may upload up to 5 attachments with a maximum file size of 3MB for all attachments.


Current Attachments


Upload an Attachment

Appointing a Representative

Link to the Appointment of Representative Form

Do you have feedback about a Cal MediConnect plan?

Contact Health Net's Customer Service       You may also communicate your concern to Cal MediConnect

Health Net Community Solutions, Inc. is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

H3237_2018_0036_MP CMS Approval pending

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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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This Schedule of Benefits is a brief list of benefits, with applicable copayments, coinsurance and deductibles information for your health plan. It does not list the exclusions and limitations or other important terms applicable to your plan.

For more information, please review carefully the disclosure form for your plan. It includes additional terms and information on certain exclusions and limitations.

The Evidence of Coverage (EOC) for your plan contains the complete terms and conditions of your Health Net coverage. It is important for you to thoroughly review the disclosure form and EOC for your plan, especially those sections that apply to those with special health care needs. You may view your Evidence of Coverage by: closing the current window and clicking on MY MEDICAL BENEFITS.

You may request copies of the forms referenced above for your health plan by: closing this window and clicking on Contact Us at the top of any web page.
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This enrollee's premiums are past due. Coverage will be suspended if premiums remain past due for more than 1 month. When coverage is suspended, outstanding authorizations for service are no longer valid. And there is no further coverage for any services rendered unless premiums are paid in full by the end of a 3 month grace period. Please contact us for more information.

This enrollee's premiums are more than 1 month past due. Coverage is currently suspended due to non-payment of premiums. Outstanding authorizations for service are no longer valid. There is no further coverage for any services rendered unless premiums are paid in full by the end of a 3 month grace period. Please contact us for more information.

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