Overview
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net's provider dispute resolution process ensures correct routing and timely consideration of provider disputes (or appeals). Participating providers use this process to:
- Appeal, challenge or request reconsideration of a claim (including a bundled group of similar claims) that has been denied or adjusted by Health Net.
- Respond to a contested claim that the participating provider does not agree requires additional information for adjudication. A contested claim is one for which Health Net needs more information in order to process the claim.
- Challenge a request by Health Net for reimbursement for an overpayment of a claim.
- Seek resolution of a billing determination or other contractual dispute with Health Net.
- Appeal a participating physician group's (PPG's) written determination following its dispute resolution process when the dispute involves an issue of medical necessity or utilization review, to Health Net for a de novo review, provided the appeal is made within 60 business days of the PPG's written determination.
- Challenge capitated PPG or hospital liability for medical services and payments that are the result of Health Net decisions arising from member grievances, appeals and other member services actions.
- Challenge capitation deductions that are the result of Health Net decisions arising from member billings, claims or member eligibility determinations.
Health Net does not charge providers of service who submit disputes to the Health Net Provider Appeals Unit or the Health Net Medi-Cal Appeals Unit for processing provider disputes and does not discriminate or retaliate against a participating provider who uses the provider dispute process. Further, providers participating through a Health Net PPG cannot be charged a processing fee when utilizing the PPG's provider dispute process.
Disputes regarding the denial of a referral or a prior authorization request are considered member appeals. Although participating providers may appeal such a denial on a member's behalf, the member appeal process must be followed. Refer to the Dispute Resolution and Appeals topic for additional information.
In addition to the provider dispute resolution process (PDF), a provider inquiry process is available for routine claim follow-up when a participating provider wants to:
- Inquire regarding the status of a claim or obtain payment calculation clarification.
- Resubmit contested claims with the missing information requested by Health Net.
- Submit a corrected claim (additional charges previously not submitted).
- Clarify member responsibility.
To check the status of an appeal or dispute, contact the applicable Health Net Provider Services Center for members:
Overview for Physicians
Health Net's provider dispute resolution process ensures correct routing and timely consideration of provider disputes (or appeals). Participating providers use this process to:
- Appeal, challenge or request reconsideration of a claim (including a bundled group of similar claims) that has been denied or adjusted by Health Net.
- Respond to a contested claim that the participating provider does not agree requires additional information for adjudication. A contested claim is one for which Health Net needs more information in order to process the claim.
- Challenge a request by Health Net for reimbursement for an overpayment of a claim.
- Seek resolution of a billing determination or other contractual dispute with Health Net.
- Appeal a written determination when the dispute involves an issue of medical necessity or utilization review, to Health Net for a de novo review, provided the appeal is made within 60 business days of the written determination.
Health Net does not charge providers of service who submit disputes to the Health Net Provider Dispute - Commercial Appeals Unit, the Health Net Provider Appeals Unit - IFP or the Health Net Medi-Cal Appeals Unit for processing provider disputes and does not discriminate or retaliate against a participating provider who uses the provider dispute process.
Disputes regarding the denial of a referral or a prior authorization request are considered member appeals. Although participating providers may appeal such a denial on a member's behalf, the member appeal process must be followed. Refer to the Dispute Resolution and Appeals topic for additional information.
In addition to the provider dispute process, a provider inquiry process is available for routine claim follow-up when a participating provider wants to:
- Inquire about the status of a claim or obtain payment calculation clarification.
- Resubmit contested claims with the missing information requested by Health Net.
- Submit a corrected claim (additional charges previously not submitted).
- Clarify member responsibility.
To check the status of an appeal or dispute, contact the applicable Health Net Provider Services Center for members: