Appeals filed by the provider on behalf of the member require written consent from the member. Appeals received after the 60-day time frame are not considered. Upon request, Medi-Cal Member Services Department, Community Health Plan of Imperial Valley Member Services Department or CalViva Health Medi-Cal Member Services Department (for Fresno, Kings and Madera counties) representatives are available to assist members in writing an appeal. An appeal must include any additional or supporting information the member would like Health Net to consider.

Medi-Cal pharmacy benefits are administered through the Department of Health Care Services (DHCS) fee-for-service delivery system called Medi-Cal Rx. Appeals and grievances for outpatient pharmacy benefits and services are not Health Net’s responsibility and must be directed to Medi-Cal Rx.

Members may receive a written notice of adverse benefit determination as a notice of action (NOA) regarding a denial, delay, modification, or termination. If a member received a NOA, the following options are available:

The member can ask for an appeal. Or, they can have someone like a relative, friend, advocate, doctor, or attorney ask for one for them. This person is called an Authorized Representative. The member’s health plan can provide a form for them to identify their Authorized representative. The member, or their Authorized Representative, can send in anything they want their health plan to look at to make a decision on their appeal. A doctor who is different from the doctor who made the first decision will look at the member’s appeal

A provider may also submit an appeal on behalf of the member or an authorized representative, when the member is challenging a denial of a prior authorization request or a service. Appeals filed by the provider or authorized representative, on behalf of the member, require written consent from the member or authorized representative. Members have a right to access their medical records. Written authorization from the member or the member’s authorized legal representative must be obtained before medical records are released to anyone not directly concerned with the member's care, except as permitted or as necessary for administration by the Health Plan.

These appeals are considered member appeals, not provider appeals. They are processed in the same manner as an appeal submitted by a member:

Health Net, its PPGs and participating providers will not discriminate against members who have filed an appeal in accordance with Title 28, CCR 1300.68(b)(8). Health Net does not take any punitive action against a provider who requests an expedited appeal or supports a member's appeal. Further, Health Net does not prohibit, or otherwise restrict, a provider acting within the lawful scope of practice from advising or advocating on behalf of a member, who is his or her patient for:

When the Health Net Medi-Cal Member Appeals and Grievances Department receives the appeal, it is assigned a case number, is researched and resolved. A written acknowledgment is mailed to the member within five calendar days of receipt of the written standard appeal. Within 30 calendar days of receipt of a standard appeal and within 72 hours of receipt of an expedited appeal, members are sent a written Notice of Appeal Resolution (NAR), stating the decision made and the rationale for that decision. An NAR is a formal letter informing a beneficiary that an adverse benefit determination has been overturned or upheld.

If Health Net upholds the initial denial of coverage, the member has the following options:

Members can request an expedited appeal if his or her health or ability to regain maximum function could seriously be harmed by waiting for a standard service appeal. A member or provider, acting on behalf of a member and with written consent from the member, may file an expedited appeal either orally or in writing to resolve the expedited appeal within 72 hours of receipt.