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Appeals & Grievances

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 a request that you make when you want us to change a decision we have made about what is covered or what we will pay for. You need to send an appeal request regarding medical care by 90 calendar days from the date on the denial letter that you get from us. After 90 days, Health Net can take an appeal request if you give us a good reason. You need to send an appeal request regarding Part D prescription drugs by 60 calendar days from the date on the denial letter that you get from us. After 60 days, Health Net can take an appeal request if you give us a good reason.

To ask for an appeal, you can call, mail, fax, or submit a request online as outlined in the "How to File an Appeal or Grievance" section below. If you submit via Mail or Fax, please put dates, times, names of people and places in your letter. Or you can fill out the Medical Services – Reconsideration Form (below). You do not need to use the form if you do not want to. Please include copies of any information about your appeal in the letter and mail to:


Medical Services:

Health Net
Attn: Appeals & Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422


Prescription Services:

Health Net
Attn: Appeals & Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422

You may also call us at 1-855-464-3571 (Los Angeles); 1-855-464-3572 (San Diego County). Send your letter by mail, e-mail or fax to the address(s) and/or fax number listed below in the How to File section.

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

For a decision to authorize medical care and payment (including Tier 3 drugs) of services: 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, 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.

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

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

You, any doctor, or your representative can ask us to give you an expedited ("fast") appeal. We can give you a fast appeal only for drugs or services that you have not received yet. You can ask for a fast appeal if you or your doctor think that waiting could seriously harm your health. If we give you a fast decision, we will decide no later than 72 hours of getting your request. For a fast appeal, contact us by telephone or fax at the number listed below in the How to File section.

For denials of medical appeals for Medicare covered services (including services that are covered by both Medicare and Medi-Cal): If we deny any part of your medical appeal, your case will be sent to an independent review organization. This independent review organization contracts with the Federal government and is not part of our Plan.

For denials of medical appeals for Medi-Cal covered services: You may request a State Fair Hearing at anytime without asking us (health plan) to review our decision first. Your request must be submitted in writing. The request must include:

  • Your name
  • Address
  • Member number
  • Reasons for appealing
  • Any evidence you want us to review, such as medical records, doctor's letters, or other information that explains why you need the item or service. Call your doctor if you need this information.

Send your request to:

State Hearings Division
Department of Social Services
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

You can ask for an Independent Medical Review (IMR) for Medi-Cal covered services and items (not including In Home Supportive Services). You must file an appeal with us before requesting an IMR. If you disagree with our decision, you can request an IMR. You cannot ask for an IMR if you already asked for a State Fair Hearing on the same issue. To request an IMR:

  • Fill out the Complaint/Independent Medical Review (IMR) Application Form available at dmhc.ca.gov - Independent Medical Review Application Form or call the DMHC Help Center at 1‑888‑466‑2219. TDD users should call 1‑877‑688‑9891.
  • Attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
  • Mail or fax your form and any attachments to:

    Help Center
    Department of Managed Health Care
    980 Ninth Street, Suite 500
    Sacramento, CA 95814-2725
    FAX: 916-255-5241

For denials of Part D appeals: If we deny any part of your Part D appeal, you or your representative can mail or fax your written appeal request to the independent review organization. Send a written appeal request to:

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

Fax number for enrollees: 1-585-425-5390

The independent reviewer will look at our decision. If any of the medical care or service you asked for is still denied, you can appeal to an Administrative Law Judge (ALJ). You will be notified of your appeal rights if this happens.

There is another special type of appeal that is only for 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 at once to Livanta. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. Livanta is an independent organization. It is not connected with our plan. See "How to File" section below to contact Livanta.

  • If you get the notice 2 days before your coverage ends, you must appeal 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 appeal 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 sections of the Member Handbook for your plan as outlined below. You can also call Health Net Customer Service at the phone number listed below in the How to File section.

Plan Name Appeals Member Handbook Section
Health Net Cal MediConnect (MMP) Chapter 9, section 5 (Medical Care) & section 6 (Part D Prescription Drugs)

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
  • Tell Medi-Cal about your complaint by calling the Cal MediConnect Ombuds Program at 1‑855‑501‑3077. The services are free. Or you may visit their website at: http://www.calduals.org/beneficiaries/ombudsman-program/
  • Obtain a total number of Health Net's complaints, appeals and exceptions, please call Health Net Customer Service at the phone number listed below in the How to File section.

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

Grievances

A grievance is a complaint that you give to your health plan. You can file a complaint when you are unhappy with any service or benefit that you get from Health Net's Cal MediConnect Program. For example, you would file a complaint if you had a problem with:

  • waiting times for appointments
  • wait time in the waiting room
  • the way your doctors or staff behave
  • being able to reach someone by phone
  • getting information you need from the doctor's office
  • the cleanliness of the doctor's office

You must file your complaint with us or the provider within 180 calendar days from the day the incident or action occurred that caused you to be dissatisfied.

The Appeals and Grievances Department can only work on complaints filed against Health Net and our contracted providers.

You can send us a complaint using one of the ways below:

  • Call Health Net's Customer Service Department
    Los Angeles: 1-855-464-3571    TTY 711
    San Diego: 1-855-464-3572       TTY 711
  • Send a letter, fax (facsimile) or e-mail to Health Net at address listed below in the How to File section
  • You may file a complaint through Cal MediConnect Ombuds Program
  • For Medicare services, you may also file a complaint through 1-800-Medicare

The Customer Service Center will try to find an answer for your complaint right away. You can ask them to send you a letter that tells you what the answer was for your complaint. If the Customer Service Center can't help you right away, they will send the complaint to be researched.

We must get back to you with what we found out about your complaint as quickly as possible. We will send you a letter no later than 30 calendar days after we get your complaint.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," or we decided we need more time to review your request for a medical care or appeal of denied medical care we will automatically give you a "fast complaint" and respond to your complaint within 24 hours. If you have an urgent problem that involves an immediate and serious risk to your health, you can request a "fast complaint" and we will respond within 72 hours. We may take up to 14 more calendar days if we need more information from you or your doctor for medical appeals on services you have not received. You can ask us for more time to send in information also.

If you have questions about these complaint procedures you may refer to the applicable sections of the member handbook. You can call Health Net Customer Service at the phone number listed below in the How to File section.

Plan Name Grievance Member Handbook Section
Health Net Cal MediConnect (MMP) Chapter 9, section 10

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

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
  • Tell Medi-Cal about your complaint by calling the Cal MediConnect Ombuds Program at 1‑855‑501‑3077. The services are free. Or you may visit their website at: http://www.calduals.org/beneficiaries/ombudsman-program/
  • Obtain a total number of Health Net's complaints, appeals and exceptions; please call Health Net Customer Service at the phone number listed below in the How to File section.

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

Complaints about the quality of care received under Cal MediConnect can be reviewed by Health Net under the complaint 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 a complaint filed under Health Net's grievance process. For any complaint filed with the QIO, Health Net will work 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 complaint with a QIO does not need to file the complaint within a specific time period. Please see below in the 'How to File an Appeal or Grievance' section for specific contact information.

How to file an Appeal or Grievance

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


  • Call our Customer Service Department
    Monday through Friday, 8:00 a.m. to 8:00 p.m.
    At other times, including Saturday, Sunday and Federal Holidays, you can leave a voicemail.
    Health Net Cal MediConnect (MMP)- Los Angeles: 1-855-464-3571
    TTY 711
    Health Net Cal MediConnect (MMP)- San Diego: 1-855-464-3572
    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 (Use of Online Form is optional)

    Medical Appeal Form

    REQUEST FOR RECONSIDERATION (APPEAL) Part C
    Your request for reconsideration (appeal) must be made within 90 calendar days from the date of the initial denial decision. If your request for reconsideration (appeal) is submitted beyond 90 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.

    Prescription Drug Appeal Form

    Important Note: Expedited Decisions

    If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. We will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

    Grievance Form

    Use this form to formally express your dissatisfaction with the care or service(s) you have received. It will be submitted to the Appeals and 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 found below. Please mail or fax to:

    Prescription Drug Services and Medical Services:

    Health Net Community Solutions, Inc.
    Attn: Appeals & Grievances Dept.
    P.O. Box 10422
    Van Nuys, CA 91410-0422

    Fax: 1-877-713-6189

  • Forms
    Medical Services – Reconsideration Form (pdf)
    Prescription Drugs – Redetermination Form (pdf)

Appointing a Representative

An appointed representative is a person who can act on your behalf to request an exception appeal or complaint. This person can be a relative, friend, advocate, doctor, or anyone else whom you trust to act on your behalf. If you want to appoint someone to act for you, then both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Please note that your physician or other prescriber is not required to submit a signed Appointment of Representative (AOR) form CMS-1696 or other equivalent notice. Physicians and other prescribers may request a redetermination on your behalf at any time without completing an AOR form.

You can use the AOR form or you can make your own statement.

The signed AOR form or other equivalent notice must be included with each oral or written request for an appeal or grievance. Unless revoked, an appointment is considered valid for one year from the date that the representative form is signed by both the member and representative. Also the representation is valid for the duration of the appeal or grievance. A photocopy of the signed representative form must be submitted with future appeals or grievances on behalf of the Member in order to continue representation. However the original or photocopied form is only valid for one year after the date of the member's signature.

You can use the form or you can make your own statement (an equivalent written notice) as long as it contains all the required information. In addition, Cal MediConnect may also accept other forms of legal documentation.

The required information of an 'equivalent written notice' is one that:

  • Includes the name, address, and telephone number of enrollee;
  • Includes the enrollee's HICN [or Medicare Identifier (ID) Number];
  • Includes the name, address, and telephone number of the individual being appointed;
  • Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative;
  • Is signed and dated by the enrollee making the appointment; and
  • Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment

Send your AOR form or equivalent written notice to:

Appeals and Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422

Information last updated 11-29-2016

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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.

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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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You have to buy health coverage through Covered California to get financial help from the government. You can click our link below to see if you qualify. Then Health Net can help you sign-up.

About Plan Years

Health plan choices may change from year-to-year. There may be new plan choices. Or changes in costs and benefits. Choose the year that matches when you want coverage to start. For example, click 2018 if you are looking at choices for next year. Have a special enrollment period for this year? Then click 2017. Note that the first effective date for our 2018 plans is January 1, 2018.

About Plan Levels

Health plans for individuals and families come in four metal levels: platinum, gold, silver and bronze. The difference between the levels is how much you pay versus how much the health insurance company pays.

There is also a minimum coverage option for people under 30. It’s also for people having financial hardship.

Health Net offers plans in all metal levels. So we have an option for you no matter what level of coverage you want.

About Plan Types

We offer several types of plans. There are HMO and HSP plans offered by Health Net of California, Inc. PPO and EPO insurance plans are offered by Health Net Life Insurance Company.

With an HMO, you have one main doctor called a primary care physician who coordinates all your care. You see your PCP for checkups, advice and care when sick or hurt. Your doctor refers you to other services when you need them. You get all services from the HMO network. There is no coverage if you see doctors who are not in the network, except in an emergency.

EPO and HSP plans have one network to use for all covered services. There is no coverage for services received outside of the network, except in an emergency or for urgent care. With EPO and HSP plans, you are required to pick a primary care physician (PCP) – a main doctor to see for checkups, advice and care when sick or hurt. Members can go directly to any doctor or specialist in the network without the need for a referral.

PPO plans give you the choice to go directly to any doctor. You can see a doctor in the PPO provider network. Or you can visit a doctor outside our network. You generally pay less out-of-pocket when you go to a doctor that is in the PPO network.

You have a PCP PCP referral needed before you get services Have one network for all services OK to get services outside of the network
HMO Yes Yes Yes, CommunityCare No, except as noted above.
EPO Yes No Yes, PureCare One No, except as noted above.
HSP Yes No Yes, PureCare No, except as noted above.
PPO No No No. Using the PPO network is your choice. When you do, you generally pay less out-of-pocket! Yes

About Financial Help

You can buy health coverage directly from Health Net. We are also a part of Covered California® so you can buy a Health Net plan through the marketplace.

You have to buy health coverage through Covered California to get financial help from the government. You can click our link below to see if you qualify. Then Health Net can help you sign-up.

About Pediatric Dental

Special Needs Plan Disclaimer

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