Member Appeals Overview

A member appeal is a request for reconsideration of a prior authorization denial for a service. Member appeals may be submitted by the member, or the provider on the member's behalf, verbally or in writing, within 60 calendar days of receipt of a denial for prior authorization or receipt of a notice of action (NOA) to the Health Net Medi-Cal Member Appeals and Grievances Department. 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 Benefit Carve Out - Medi-Cal Rx

Medi-Cal pharmacy benefits are administered through the Department of Health Care Services (DHCS) fee-for-service delivery system called Medi-Cal Rx. Health plan Medi-Cal pharmacy benefits and services transitioned to the State’s responsibility under the pharmacy benefit program known as Medi-Cal Rx (DHCS APL 20-020). Appeals and grievances for these benefits and services are not Health Net’s responsibility.

• Medi-Cal Rx member appeals – Appeals involving disagreement with benefit-related decisions, such as coverage disputes, disagreeing with and seeking reversal of a request for prior authorization involving medical necessity, etc., and are associated with a Notice of Action (NOA), should be directed to California Department of Social Services (CDSS) State Fair Hearing (SFH) and not to Health Net.

Medical beneficiaries are no longer required to exhaust any internal and/or administrative DHCS processes prior to requesting a SFH through CDSS. Additionally, under Medi-Cal Rx, Medi-Cal enrollees no longer have the right to apply for an Independent Medical Review (IMR) for pharmacy services carved out to Medi-Cal Rx (DMHC APL 20-035). If Health Net receives an appeal related to these services, it will redirect it to CDSS State Fair Hearing in a timely manner and in the manner outlined by DHCS.

• Member complaints and grievances – A Health Net or CalViva Health Medi-Cal member may file Medi-Cal Rx complaints and grievances at any time to the Medi-Cal Rx Customer Service Center (CSC), who will administer all aspects of the complaints and grievances processes and related procedures for Medi-Cal pharmacy benefits. Complaints or grievances may be filed with the Medi-Cal Rx CSC phone or in writing via fax. If the health plan receives a Medi-Cal Rx grievance or complaint, it will redirect those issues to the Medi-Cal Rx CSC.
• Provider prior authorization (PA) appeals – Providers, on behalf of a Medi-Cal beneficiary, may appeal Medi-Cal Rx PA denials, delays and modifications issued on or after January 1, 2022. Providers may submit appeals of PA adjudication results through their Medi-Cal Rx or by mail clearly identified as appeals.

Medi-Cal Rx will acknowledge each submitted PA appeal within three days of receipt and make a decision within 60 days of receipt. Medi-Cal Rx will send a letter of explanation in response to each PA appeal. Providers who are dissatisfied with the decision may submit subsequent appeals. Medi-Cal providers may seek a judicial review of the appeal decision, as authorized under state law. For more information about the Medi-Cal Rx provider PA appeal process, please visit Medi-Cal Rx.

• Provider claim appeals – Provider claim appeals to resolve claim payment problems (e.g., resubmission, non-payment, underpayment, overpayment, etc.) for services provided on or after January 1, 2022, may be filed to Medi-Cal CSC. Providers must complete the Medi-Cal Rx provider appeal form and submit the completed form Medi-Cal Rx.

Once the Medi-Cal Rx provider appeal form is submitted, Medi-Cal Rx will acknowledge each appeal within 15 days of receipt and make a decision within 45 days of receipt.

The above information about appeals and grievances related to pharmacy was adapted from Department of Managed Health Care All Plan Letter 20-035, DHCS All Plan Letter 20-020 and the Medi-Cal Rx.

Notice of Action

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 has 60 calendar days from the date on the NOA to file an appeal of the NOA with Health Net.
• The member may request an independent medical review (IMR) from the Department of Managed Health Care (DMHC) after first filing an appeal with Health Net, or right away if the member's health is in immediate danger or if the request was denied because treatment is considered experimental or investigational.

Availability of Member Assistance in Filing an Appeal

The member can ask for an appeal. Or, they can have someone like a relative, friend, advocate, doctor, or attorney to ask for one for them. This person is called an Authorized Representative. The members 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, not the participating physician group (PPG) or subcontractor, processes the appeal.
• Health Net's decision is final. There is no second-level appeal between Health Net and the PPG.
• Providers do not have the option of requesting a fair hearing with the Department of Social Services (DSS).

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 support's 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:

1. The member's health status, care, or treatment options, including any alternative treatment that may be self-administered.
2. Any information the member needs in order to decide among all relevant treatment options.
3. The risks, benefits, and consequences of treatment or non-treatment.
4. The member's right to participate in decisions regarding his or her care, including the right to refuse treatment, and to express preferences about future treatment decisions.

Appeal Resolution Process

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 appeal. Within 30 days of receipt of a standard appeal and with 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.

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

• Member may apply to the DMHC for an Independent Medical Review (IMR) within 180 days from the date of the NAR letter or after exhausting the plan’s grievance and appeals process. However, the member may request an Independent Medical Review (IMR) from the DMHC right away if the member’s health is in immediate danger or if the request was denied because treatment is considered experimental or investigational; otherwise, the member must first file an appeal with the plan.
• The member may request a state hearing by phone or in writing from the California Department of Social Services (DSS) only after receiving an NAR and within 120 calendar days from the date of the NAR letter. Members may continue to receive benefits during the hearing process, and have the right to representation by legal counsel, a friend or other spokesperson during the process.

Notice of Appeals Resolution

Members may receive a written notice of appeals resolution (NAR), which is a formal letter informing a beneficiary that an adverse benefit determination has been overturned or upheld.

Expedited Appeals

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.

Covered Services

Health Net must pay for disputed services if the member receives these services while the appeal is pending.

Health Net will continue benefits while a member appeal is pending for the following:

• Appeal involves the termination, suspension or reduction of previously authorized services.
• Member filed their appeal within the required timeframes.
• Covered services were ordered by an authorized provider.
• Period covered by the original authorization has not expired.
• Member files for continuing covered services within 10 calendar days of when the NOA was sent, or before the intended effective date of the proposed action.
• Until the member withdraws his or her appeal or request for a state hearing, the member fails to request a state hearing and continuation of covered services within 10 calendar days of when the NOA was sent, or the state hearing decision is adverse to the member.