Appeals and Grievances
Provider Type
- Participating Physician Groups (PPG)
Health Net does not delegate member appeals or grievances, except for Molina. The Health Net State Health Programs Quality Improvement Health Equity Committee (QIHEC) reviews quarterly Medi-Cal appeals and grievance reports to assess emerging patterns of appeals and grievances, and to formulate potential plan policy/process changes and/or procedural improvements.
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.