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)