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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.

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.

Location Phone Number
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

Livanta 
BFCC-QIO Program
9090 Junction Drive, Suite 10 
Annapolis Junction, MD 20701

Contact Method Phone or Fax Number
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 

Medical Appeal Form (Use of Online Form is optional)

REQUEST FOR RECONSIDERATION (APPEAL) Part C

Your request for reconsideration (appeal) must be made within 60 calendar days from the date of the initial denial decision. If your request for reconsideration (appeal) is submitted beyond 60 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.

You (the enrollee), your provider or your representative can request an appeal. Representation documentation is required for appeal requests made by someone other than the Enrollee or the Enrollee's provider. Attach documentation showing the authority to represent the Enrollee (a completed Authorization of Representation Form CMS-1696 (pdf) or a written equivalent) if it was not already submitted at the coverage determination level. For more information on appointing a representative, contact our Customer Service Department.

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 


Information last updated: 07/11/2018
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