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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:
 

  • By calling our Member Services 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
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)

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 or a written equivalent) if it was not already submitted at the coverage determination level. For more information on appointing a representative, contact our Member Services Department.

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 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 


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 Community Solutions, Inc - Medicare-Medicaid Plan (MMP)
Attn: Appeals & Grievances Department
P.O. Box 10422
Van Nuys, CA 91410-0422

For more information, call Member Services at 1-855-464-3571 in Los Angeles or 1-855-464-3572 in San Diego. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day. TTY users call 711.