Appeals and Grievances

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 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. This also applies for Part D; 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 Filing an Appeal or Grievance section. 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 in the Filing an Appeal or Grievance 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 in the Filing an Appeal or Grievance 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 may be able to get an IMR right away without filing an appeal first. This is in cases where your health is in immediate danger or the request was denied because treatment was considered experimental or investigational. 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. 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 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 the Filing an Appeal or Grievance section 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 in the Filing an Appeal or Grievance 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 in the Filing an Appeal or Grievance section.

If you want to ask about the status of an appeal, please call Health Net Customer Service at the phone number listed in the Filing an Appeal or Grievance section.

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 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 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 in the Filing an Appeal or Grievance 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 in the Filing an Appeal or Grievance 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 in the Filing an Appeal or Grievance 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 in the Filing an Appeal or Grievance 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 the Filing an Appeal or Grievance section for specific contact information.


Information last updated: 07/11/2018
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