Non-contracted Provider Appeals
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net is a Medicare Advantage organization and as such, is regulated by the Centers for Medicare & Medicaid Services (CMS). In accordance with CMS regulations, providers who are not contracted with a Medicare Advantage organization may file a standard appeal for a claim that has been denied, in whole or in part, but only if they submit a completed Waiver of Liability Statement (PDF). If you complete a Waiver of Liability Statement, you waive the right to collect payment from the member, with the exception of any applicable cost sharing, regardless of the determination made on the appeal.
If you appeal and we uphold the denial, in whole or in part, you will have additional appeal rights available to you including, but not limited to, reconsideration by a CMS contracted independent review entity.
To appeal, mail your request and completed Waiver of Liability Statement (PDF) within 60 calendar days after the date of the Notice of Denial of Payment by either the Plan or the PPG, to Wellcare By Health Net - Appeals.
Non-contracted provider appeal includes:
- Appeal, challenge or request reconsideration of a claim (including a bundled group of similar claims) that has been denied or adjusted by the plan.
- Respond to a contested claim that the participating provider does not agree requires additional information for adjudication. A contested claim is one for which the plan needs more information in order to process the claim.
- Challenge a request by the plan for reimbursement for an overpayment of a claim.
- Challenge PPG or hospital liability decision to pay for a different service or level than billed. Some other reasons for payment appeals are:
- Bundling issues
- Diagnosis related group (DRG) payments
- Downcoding.
- Challenge PPG or hospital liability denial of service(s).
- Challenge capitation deductions that are the result of the plan decisions arising from member billings, claims or member eligibility determinations.