Dispute Submission
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net accepts disputes, including appeals, from participating providers if they are submitted within 365 days of receipt of Health Net's decision (for example, denial or adjustment), except as described below. If the participating provider does not receive a decision from Health Net, the dispute must be submitted within 365 days after the deadline for contesting or denying the claim has expired. If the participating provider's Provider Participation Agreement (PPA) provides for a dispute-filing deadline that is greater than 365 calendar days, this longer time frame continues to apply until the contract is amended.
When submitting a provider dispute, a provider should use the Provider Dispute Resolution Request form - Provider Dispute Resolution Request form - Health Net (PDF), Provider Dispute Resolution Request form – Community Health Plan of Imperial Valley (PDF) or Provider Dispute Resolution Request form - CalViva Health (PDF). If the dispute is for multiple, substantially similar claims, the Provider Dispute Resolution Request spreadsheet (page two of the request form above and up to 12 claims) or the Claims Project Submission Universal Template spreadsheet (used for more than 12 claims) should be submitted with the Provider Dispute Resolution Request form. The Claims Project Submission Universal Template spreadsheet should be requested from your Provider Network Management contact. Provider Network Management will email you a copy of the spreadsheet template to complete and submit along with the Provider Dispute Resolution Form.
The provider dispute must include:
- The provider's name; identification (ID) number; contact information, including phone number; and the original claim number.
- If the dispute is regarding a claim or a request for reimbursement of an overpayment of a claim, the dispute must include: a clear identification of the disputed item; the date of service; and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect.
- If the dispute is not about a claim, the provider must include a clear explanation of the reason for the dispute, including, if applicable, relevant references to the PPA.
A provider dispute that is submitted on behalf of a member is considered a member appeal and is processed through the member appeal process. Providers may submit member appeals using the Provider Dispute Resolution Request form below.
- Health Net Member Appeals and Grievances Department (HMO, HSP, PPO and EPO)
- Medi-Cal Member Appeals and Grievances Department (Health Net Medi-Cal, Community Health Plan of Imperial Valley or CalViva Health).
Submit disputes to the Health Net Provider Appeals Unit (HMO, HSP, PPO and EPO) or the Medi-Cal Provider Appeals Unit (Health Net Medi-Cal, Community Health Plan of Imperial Valley or CalViva Health).
Providers who participate under a capitated agreement with a participating physician group (PPG) must submit disputes to the PPG that processed the claim.