Appeals and Grievances

Health Net does not delegate member appeals or grievances. The Health Net State Health Programs Utilization Management/Quality Improvement Committee reviews quarterly Medi-Cal appeals and grievance reports.

For more information on member appeals or grievances, refer to the discussions of Member Appeals and Grievances.

Outpatient Pharmacy Benefits and Services Carve Out

Health Net Medi-Cal pharmacy benefits and services transitioned from managed care to the State’s responsibility under the pharmacy benefit program known as Medi-Cal Rx. Appeals and grievances for these benefits and services are the responsibility of Medi-Cal Rx. Disputes regarding the denial of a referral or a prior authorization request should be directed to DHCS State Fair Hearing and not to Health Net. If Health Net receives a grievance related to these services, Health Net will redirect those grievances to Medi-Cal Rx contractor, Magellan Medicaid Administration, Inc. (Magellan), in a timely manner and in the manner outlined by DHCS. If Health Net receives an appeal related to these services, DHCS State Fair Hearing process is responsible. Health Net will redirect those appeals to DHCS State Fair Hearing.