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) 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 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 below in the How To File section.
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 below in the How To File section.
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 Health Services Advisory Group, which is the Quality Improvement Organization in the state of California.
- 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 Pharmacy 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 below in the How To File section.
||Appeals EOC Section
|All Health Net Healthy Heart (HMO) plans, All Health Net
Seniority Plus Ruby (HMO), All Health Net Ruby Select(HMO)
plans, Health Net Gold Select (HMO), Health Net Jade
(HMO SNP), All Health Net Violet (PPO) plans
|Chapter 9, section 5 (Medical Care) &
section 6 (Part D Prescription Drugs)
|Health Net Seniority Plus Green (HMO)
||Chapter 7, section 5 (Medical Care)
|All Health Net Seniority Plus Amber (HMO SNP) plans
||Chapter 9, section 6 (Medical Care) &
section 7 (Part D Prescription Drugs)
If you want to inquire about the status of an appeal, please call Health Net Customer Service at the phone number listed below in the How To File section.