Reconsideration Reversal

If Health Net does not make a fully favorable decision on a standard service reconsideration, and if on reconsideration, Health Net's determination is reversed in whole or in part by MAXIMUS, Health Net must authorize the service within 72 hours from the date it receives the notice reversing the determination, or provide the service as quickly as the member's health requires (but no later than 14 calendar days from that date). Health Net must inform MAXIMUS that it has complied with the decision.

Administrative Law Judge Reconsideration

If MAXIMUS issues an appeal denial upholding a plan denial, and this determination is reversed in whole or in part by the Administrative Law Judge (ALJ), or at a higher level of appeal, then Health Net must authorize or provide the service as expeditiously as the members' health requires, but no later than 60 calendar days from the date it received the notice reversing the MAXIMUS determination. The plan must also inform MAXIMUS that it has complied with the decision.

For additional information, refer to Administrative Law Judge.