MAXIMUS Federal Services

If Health Net Medicare Advantage (MA) upholds the initial determination in whole or in part, or fails to provide the member with a reconsideration determination within 30 days (pre-service) or 60 days (post-service) of the receipt of the request, it must forward the case file to the Centers for Medicare & Medicaid Services' (CMS) contractor, MAXIMUS Federal Services, no later than 30 calendar days (pre-service) or 60 calendar days (post-service) after receiving the reconsideration request. Health Net concurrently notifies the member that it has forwarded the case to MAXIMUS. Health Net prepares the file for MAXIMUS by providing the following:

• Cover sheet with member name and health insurance number
• Case summary
• Chronology of events
• Supporting documentation
• Reconsideration checklist (used to assure that the file has what is needed - not to be submitted to MAXIMUS)

If the decision is overturned by MAXIMUS, following its receipt of notice of the overturn, Health Net must pay, authorize or provide the service in question as quickly as the member's health requires, but no later than 30 days from notification that payment is required for post-service appeals, no later than 72 hours from notification that an authorization must be made, or no later than 14 days from notification that a service must be provided for pre-service appeals, respectively. Health Net is required to comply with the decision made by MAXIMUS and must inform MAXIMUS of the action taken. After the decision is adjudicated, Health Net can appeal a MAXIMUS decision, and then that final MAXIMUS determination is binding on the plan and the participating physician group (PPG).