Procedures and Requirements
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The Centers for Medicare & Medicaid Services (CMS) requires all Medicare Advantage organizations (MAOs) and delegated participating providers to have a process in place for members to appeal all service and claim denials. If Health Net or one of its participating providers denies a request for service, or a request for authorization of a payment or claim, in whole or in part, it is defined as an adverse organization determination or denial. Health Net does not delegate member appeals and grievances. All Health Net MA member appeals and grievances should be forwarded immediately to the Health Net MA Appeals and Grievances Department. Health Net prefers receiving appeals and grievances by fax, which enables Health Net to process and resolve a member's issue quickly in accordance with state and federal timeliness requirements.
A member's communication of an appeal may also include a grievance. Multiple issues are handled simultaneously, but separately under the specific time frames for an appeal or grievance. Each case is cross-referenced in Health Net's correspondence back to the member. The two procedures are mutually exclusive and the appeals procedure does not include binding arbitration.
Initial Determination
An initial determination is made when either Health Net or the participating provider denies payment for a service rendered or fails to provide for or authorize a requested service. Health Net or the participating provider must make an initial decision on a request for service as quickly as the member's health permits, but not later than 14 calendar days from the date of the member's request. This time frame may be extended up to an additional 14 calendar days, if it is in the member's interest.
Health Net must pay 95 percent of clean claims from non-participating providers within 30 calendar days of the request. All other claims must be paid or denied within 60 calendar days from the date of the request.
Failure to make an initial determination within the allowed time frame is deemed an adverse determination and automatically entitles the member a right to use the reconsideration and appeals process. In this situation, the member is not held to the 60-day time limit to file a request for reconsideration, and Health Net or the participating provider may be required to pay the claim or provide the service.
Requesting an Appeal
CMS defines an appeal as:
- Any of the procedures that deal with the review of an adverse organization determination regarding health care services a MA member believes they are entitled to receive, including delay in providing, arranging for, or approving the health care services (that such a delay would adversely affect the health of the member), or on any amounts the member must pay for a service.
When Health Net or a participating provider denies payment for a service rendered or fails to provide for or authorize a service requested, an appeal for reconsideration of the initial decision may be submitted to the Health Net MA Appeals and Grievances Department or the participating provider. CMS requires all requests for standard or service appeals be made in writing within 60 calendar days of the date of the written denial notice.
An extension of this time frame may be granted if the requestor demonstrates good cause for the delay in filing the appeal. The member may file this request with Health Net or their participating provider.
A member has the right to appeal any decision about payment of, or failure to arrange or continue to arrange for, what the member believes are covered services (including non-Medicare covered benefits) under Health Net's MA plan. This includes any denied medical service that the member feels Health Net should cover. Claims and requests for services must be denied before they can be appealed.
Some commonly appealed decisions include decisions regarding:
- Payment for emergency services, out-of-area urgently needed services, renal dialysis, or post-stabilization services.
- Payment for health services furnished by a non-participating medical group, provider or facility that the member believes should have been arranged for, furnished or reimbursed by Health Net.
- Services that the member has not received, but for which the member believes Health Net should arrange and pay.
- Health Net's discontinuation of services, or refusal to pay for or provide services, that the member believes are medically necessary covered services.
- Prescription copayments the member feels that he or she should not have to pay.
- General claim denials.
The following individuals have a right to request an appeal:
- The member.
- An authorized representative or assignee of the member. An authorized representative or assignee is a person authorized by state law who may sign for and make health care treatment decisions for the member. Refer to the Appointment of Representation (PDF) (AOR) (AOR - Spanish (PDF)) topic for more information.
- A legal representative of the member's estate.
- Any participating provider.
Appeal Processing
The CMS requires that MAOs and participating providers have a process in place to record and respond to all member appeal requests. The MAO or the participating provider must receive requests for appeals in writing, and all requests received orally (expedited appeals only) must be documented.
When an appeal is received, Health Net or the participating provider must:
- Document the member information, provider information, appeal issue, and the date and time the request was received.
- Fully investigate the substance of the appeal, including any aspects of clinical care, and obtain all pertinent information including medical records.
- Ensure that the review of the denied service or claim is conducted by an individual who was not involved in making the initial organization determination. If the original denial was based on a lack of medical necessity, the review must be performed by a physician with expertise in the field of medicine that is appropriate for the services at issue.
Health Net MA is required to perform the following:
- Medical director reviews the initial determination.
- Ensure the reconsideration decision is not made by the same person who was involved in making the initial determination.
- Ensure that denials due to lack of medical necessity are reconsidered by the participating provider with expertise in the medical field of the services under appeal.
- Send a notice of the decision to the requesting party stating whether a decision has been made to make full payment or provide the requested service. If the decision has been made to uphold the initial determination, the requestor is informed that the case has been forwarded to MAXIMUS Federal Services.
Notification of Appeal Determination
If Health Net makes a fully favorable decision on a standard pre-service reconsideration, it must issue a notice of the decision to the member, and authorize or provide the service, as expeditiously as the member's health requires, but not later than 30 calendar days after receiving the reconsideration request (or an additional 14 calendar days if an extension is justified).
If Health Net makes a reconsideration determination on a request for payment that is fully favorable to the member, it must issue a written notice of its reconsideration determination to the member and pay the claim no later than 60 calendar days after receiving the reconsideration request.