Administrative Law Judge
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
A Health Net Medicare Advantage (MA) member who is dissatisfied with a MAXIMUS Federal Services reconsideration of an appeal may request a hearing before an administrative law judge (ALJ). The member may file this request with Health Net Medicare Advantage (MA) or MAXIMUS. The dispute must involve at least $120. The request for a hearing must be in writing and filed within 60 calendar days from the date of the reconsideration notice. Although the plan may not appeal a MAXIMUS reconsideration decision, it is party to any ALJ hearing.
Both the plan and the member may request that the Medicare Appeals Council review an ALJ's decision if they are dissatisfied with the decision. The request for review must be within 60 days from the date Health Net receives the ALJ hearing decision. The request for appeal may be submitted directly to the Medicare Appeals Council. If the amount in controversy is at least $1,220, Health Net or the member may request judicial review of the ALJ's decision in U.S. District Court. (Amounts are subject to change annually and are established by October of the current year. Refer to www.federalregister.gov for more information.)
Any decision may be reopened by any entity that rendered a decision within four years of the notice of organization or reconsidered determination for just cause, or at any time for a clerical correction, suspected fraud, or to consider new evidence that was not available earlier.