Part C Appeals
Part C Appeals – What is an Appeal?
An appeal is a way for you to ask us to change a decision we made about your coverage. Making an appeal means trying to get the medical coverage you want.
Making an Appeal
You must make your appeal within 60 days from the date on the letter we sent to you telling you our answer to your request for coverage. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
Filing 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:
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.
- 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)
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
By Submitting an Online Form:
Medical Appeal Form (Use of Online Form is optional)
Use this form as a way to ask us to change a decision we made about your coverage.
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.
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 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
Please mail or fax your Part C (part B Drugs) Medical Services Appeals and Part C and D Grievances 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
Or by using one of our forms found below.
Part C Non-Contracted Provider Appeals
How do non-contracted providers file a claim appeal?
In accordance with the requirements established by the Centers for Medicare & Medicaid Services (CMS), non-contracted providers have Medicare appeal rights. Medicare appeal rights apply to any claim for which we have denied payment.
- All requests for payment appeals must include a completed and signed “Waiver of Liability" (WOL) Form (PDF).
- The appeals process cannot begin until a completed and signed WOL is received.
- Requests for appeals that do not include a WOL, or for which a WOL is not received within the required timeframes, will be issued a Notice of Dismissal of Appeal Request.
- Requests for payment appeals must be filed within 60 calendar days of the explanation of payment (EOP).
- A copy of the EOP and any other supporting documentation (such as medical records when applicable) must be submitted with the appeal request.
We will make a decision regarding the appeal within 60 calendar days from the date the appeal request was received with the completed Waiver of Liability.
Non-Contracted Provider Appeal Requests should be submitted, with the completed WOL, to the following address:
Health Net Community Solutions, Inc.
Attn: Appeals & Grievances Department
P.O. Box 10422
Van Nuys, CA 91410-0422
If you have questions about the Part C Medical Appeals procedures, you may refer to the appeals sections of the Member Handbook. 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.