Requesting a Standard Reconsideration

A primary care physician (PCP) may submit a standard pre-service reconsideration request on a member's behalf without completing a representation form. If the standard pre-service reconsideration request comes from a participating physician or non-participating physician, and the member's records indicate he or she visited this physician at least once before, Health Net may assume the physician has informed the member about the request and no further verification is needed. If the standard pre-service reconsideration request appears to be the first contact between the member and physician who is requesting the reconsideration, Health Net takes reasonable efforts to confirm the physician has given the member appropriate notice.

Except in the case of an extension of the filing time frame, physicians must file the request for reconsideration within 60 calendar days from the date of the notice of the organization determination. If a request for reconsideration is filed beyond the 60 calendar-day time frame without good cause for late filing, Health Net dismisses the reconsideration request and sends the written notification, CMS' Notice of Dismissal of Appeal Request, to the provider stating the reason for dismissal. Additionally, Health Net informs the provider of the right to request an independent review of the dismissal and explains that the request for review of Health Net's dismissal should be filed with the independent review entity (IRE) at MAXIMUS Federal Services.

Standard Reconsideration of a Pre-Service Request

Upon reconsideration of an adverse organization determination, Health Net must issue the reconsidered determination as expeditiously as the member's health requires and no later than 30 calendar days from the date Health Net or its delegated PPG receives the request for a standard reconsideration (and promptly forwards the appeal to Health Net). The time frame may be extended by up to 14 calendar days by Health Net if the member requests the extension, or if Health Net justifies a need for additional information and documents how the delay is in the interest of the member. When Health Net extends the time frame, the member must be notified in writing of the reasons for the delay and their right to file an expedited grievance if they disagree with Health Net's decision to grant an extension. When extensions are granted, Health Net must issue its determination as expeditiously as the member's health condition requires, but no later than the expiration date of the extension.

Occasionally, Health Net may not have complete documentation for a reconsideration request. Health Net must make reasonable efforts to obtain all necessary medical records and other pertinent information within the required time limits. If Health Net cannot obtain all relevant documentation, the reconsideration decision must be based on the material available.