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Appeals and Grievances

An appeal is the process to review a decision we made that you may not like. The negative decision is called a Coverage Determination. If our answer is no to part or all of what you asked for, we will send you a letter that explains why we said no. The letter will also explain how you can appeal our decision. You must make your appeal within 60 days from the date on the letter we sent to you. 

There are 2 kinds of appeals:

Standard Appeal – If you do not like the choice we have made, you have the right to make an appeal. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal 30 calendar days after we hear your appeal (7 days for appeals related to prescription drugs). We may take longer if you ask for more time, or if we need to know more about your case. We will tell you if we are taking extra time and will explain why more time is needed. We cannot take longer for appeals related to Part B or Part D prescription drugs.

Fast Appeal – You can ask for a fast appeal if you or your doctor think your health could be in danger. You will get an answer within 72 hours after we get your appeal. Click here to view Member Handbook.

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.

  • 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.

How to Ask for an Appeal

You, your doctor, or your appointed representative can call, mail, or fax an appeal one of the following ways:

By calling our Member Services Department

  • Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) - Los Angeles: 
    1-855-464-3571 (TTY: 711)
  • Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) - San Diego: 
    1-855-464-3572 (TTY: 711)

Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day.

By Mail or Fax


You can mail or fax your appeal via a written letter by including the following:

  • Your name
  • Your address and phone number
  • Your Member ID number
  • Your reason for the appeal
  • Medical records, notes or a letter from your doctor

Or by sending one of our forms found below.

Use this form as a way to ask us to change a decision we made about your medical services (and Part B Drugs) coverage.

Use this form as a way to ask us to change a decision we made about your Part D prescription drug coverage.

For part C (and Part B Drugs) Medical Services Appeals:

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

For Part D Prescription Drug Appeals:

Health Net Community Solutions, Inc.
Attn: Medicare Pharmacy Appeals
P.O. Box 31383
Tampa, FL 33631-3383
FAX: 1-866-388-1766

You may also call us at 1-855-464-3571 (TTY: 711) Los Angeles; 1-855-464-3572 (TTY: 711) San Diego County. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day.

For denials of Part C medical (and Part B Drugs) appeals: 

  • For Medicare covered services (including services that are covered by both Medicare and Medi-Cal):  
    If you ask for an appeal and 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 Medi-Cal covered services: 
    You may request a State Fair Hearing within 120 calendar days from the date of the Notice of Appeals Resolution (NAR). But, if you are currently getting treatment and want to continue getting treatment, you must ask for a State Hearing within 10 calendar days from the date of the Notice of Action letter or Notice of Appeal Resolution letter, OR before the date your Physician Group or Health Net Cal MediConnect says services will stop. You must say that you want to keep getting treatment when you ask for the State Hearing. 

You can ask for a State Hearing by phone or in writing:

By phone:
Call 1-800-952-5253. This number can be very busy. You may get a message to call back later. If you cannot speak or hear well, please call TTY/TDD 1-800-952-8349. 

In writing:
Fill out a State Hearing form or send a letter to: 

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

The request must include:

  • Your name
  • Your 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.

If you do not agree with the appeal decision

If you filed an appeal and received a “Notice of Appeal Resolution” letter telling you that Health Net Cal MediConnect will still not provide the services, or you never received a letter telling you of the decision and it has been past 30 days, you can:

  • Ask for an “Independent Medical Review” (IMR) and an outside reviewer that is not related to Health Net Cal MediConnect will review your case 
  • Ask for a “State Hearing” and a judge will review your case You can ask for both an IMR and State Hearing at the same time. 

You can ask for both an IMR and State Hearing at the same time. You can also ask for one before the other to see if it will resolve your problem first. For example, if you ask for an IMR first, but do not agree with the decision, you can still ask for a State Hearing later. However, if you ask for a State Hearing first, but the hearing has already taken place, you cannot ask for an IMR. In this case, the State Hearing has the final say.

Independent Medical Review (IMR)
If you want an IMR, you must first file an appeal with Health Net Cal MediConnect. If you do not hear from Health Net Cal MediConnect within 30 calendar days or if you are unhappy with Health Net Cal MediConnect's decision, then you may then request an IMR. You must ask for an IMR within 180 calendar days from the date of the “Notice of Appeal Resolution” letter. 

You may apply for an IMR without first participating in Health Net Cal MediConnect's Internal Appeal process in extraordinary and compelling cases, as determined by DMHC, and in cases where your request for an experimental treatment was denied. Health & Safety Code Section 1368.03 and 1374.31(a); Title 28, CCR Section 1300.70.4(b) (2).

The paragraph below will provide you with information on how to request an IMR. Note that the term "grievance" is talking about both "complaints" and "appeals". 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 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 Part D appeals 

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

C2C Innovative Solutions, Inc.
Part D Drug Reconsiderations
P.O. Box 44166
Jacksonville, FL 32231-4166

For mail sent by couriers such as Fedex and UPS:
C2C Innovative Solutions, Inc.
Part D QIC
301 W. Bay St., Suite 600
Jacksonville, FL 32202

Toll Free number for enrollees: 1-833-919-0198

Toll Free fax number for enrollees:
Fax: 1-833-710-0850 (for a standard decision request)
Fax: 1-833-710-0579 (for a "fast initial decision" request/appeal)

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.

If you have questions about these appeal process, you may refer to the sections of the Member Handbook for your plan as outlined below. You may also call us at 1-855-464-3571 (TTY: 711) Los Angeles; 1-855-464-3572 (TTY: 711) San Diego County. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day.

As a Health Net Cal MediConnect 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 or (TTY 1-855-847-7914). The services are free. Or you may visit their website at: http://www.calduals.org/beneficiaries/ombudsman-program/

For quality of care grievances, you may also file a complaint to a Quality Improvement Organization (QIO)

For Quality Improvement Organization (QIO) Complaints:

If you have a complaint about the quality of care received, it can be reviewed under the Health Net Cal MediConnect grievance process, by an independent organization called a QIO, or by both. For example, if you believe you are being discharged from the hospital too soon, you may file a complaint with the QIO in addition to a complaint filed with Health Net Cal MediConnect. For any complaint filed with the QIO, we will work with the QIO in resolving the complaint.

How to file a quality of care complaint with the QIO:

You must file a quality of care complaint filed in writing. A quality of care complaint with a QIO does not need to file the complaint within a specific time period.

Livanta 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.


Livanta 
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105
Toll-free Number: 1-877-588-1123
TTY: 1-855-887-6668
Fax Number: 1-833-868-4063

 

What is a grievance?

A grievance is a complaint you or your appointed representative make about Health Net’s Cal MediConnect program or one of our network providers or pharmacies. A grievance is a complaint about anything other than benefits, coverage or payment. You would file a grievance if you had problems with the quality or value of your medical care, waiting times or the customer service you receive. You would file a grievance if you did not think we responded fast enough to your request for coverage determination or organization determination, or to your appeal.

You can file your complaint with us or the provider at any time.

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

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

  • Call Health Net Cal MediConnect's Member Services.
    • Los Angeles: 1-855-464-3571 (TTY: 711)
    • San Diego: 1-855-464-3572 TTY: 711)

Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day.

  • Send a letter or fax to:

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

Fax: 1-877-713-6189

  • You may file a complaint through Cal MediConnect Ombuds Program. Call 1-855-501-3077 or (TTY 1-855-847-7914).
  • For Medicare services, you may also file a complaint through 1‑800‑MEDICARE (1‑800‑633‑4227; TTY/TDD Hearing Impaired 1‑877‑486‑2048), 24 hours a day, 7 days a week.

Member Services 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 Member Services 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 may also ask us for more time to send in information.

As a Health Net Cal MediConnect 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 or (TTY 1-855-847-7914). 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 Cal MediConnect's complaints, appeals and exceptions; please call Health Net Cal MediConnect Member Services.

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 Call MediConnect 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 Cal MediConnect's grievance process. For any complaint filed with the QIO, Health Net Cal MediConnect 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.

Livanta 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.

Livanta 
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105

Toll-free Number: 1-877-588-1123
TTY: 1-855-887-6668
Fax Number: 1-833-868-4063