State Hearing
Members may request a state hearing by phone or in writing from the California Department of Social Services (DSS) after receiving a NAR from Health Net stating that their member appeal is denied or if they have exhausted the appeals process. Members may request a state hearing up to 120 calendar days from the date on Health Net's NAR. 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.
Within two business days of being notified by the Department of Health Care Services (DHCS) or DSS that a member has filed a request for a state hearing which meets the criteria for expedited resolution, Health Net delivers directly to the designated or appropriate DSS administrative law judge all information and documents which either support, or which Health Net considered in connection with, the action which is the subject of the expedited state hearing. If the NOA or NAR notices are not in English, fully translated copies shall be transmitted to DSS along with copies of the original NOA and NAR.
If the member is currently getting treatment and he or she wants to continue getting treatment, the member may ask for a state hearing within 10 days from the date that the NAR was postmarked or delivered or before the date Health Net benefits will end or stop. The member must state that he or she wants to continue treatment when he or she requests the state hearing.
The state must reach a decision for a standard state hearing and notify the member within 90 days of the date of the request. For an expedited state hearing, the state must reach its decision within three business days of receipt of the expedited state hearing request.
Medi-Cal members must first undergo Health Net's appeal process and arbitration must be concluded before they may submit a hearing request. Members may receive continued benefits during the hearing process. Members have the right to be represented by legal counsel, a friend or other spokesperson. Filing a grievance does not waive a member's right to a hearing.
Representation and Assistance Rules at A State Fair Hearing
The member can speak for themselves at the State Hearing. Or, they can have someone like a relative, friend, advocate, doctor, or attorney speak for them. If a member wants someone else to speak for them, they must add their name, address, and telephone number to the form or letter and sign the form telling the State Hearings Division that the person can speak for them. This person is called an Authorized Representative.
The member will not have to pay for an interpreter if one is needed. The State Hearings Division will get them one. If the member has a disability, the State Hearings Division can get them special accommodations free of charge to help them participate in the hearing.
Expedited Hearing
It could take up to 90 days to decide on a case. If waiting 90 days will hurt the member’s health, they can request an expedited hearing. If the State Hearings Division approves their request for an Expedited Hearing, they may be able to get a hearing decision within 3 days from the date it receives the members case file from their health plan.
The member can ask for an Expedited Hearing by calling or sending the State Hearing form or a letter to the State Hearings Division. The member must explain how waiting for up to 90 days for a decision will harm their life, health or ability to get or keep maximum function. The member can also get a letter from their doctor to help show why they need an Expedited Hearing.