- Participating Physician Groups (PPG)
The Health Net Medicare Advantage (MA) grievance procedure applies if the nature of the member's complaint deals with involuntary disenrollment, the quality of care given to the member, delay of referral/authorization, access to care concerns, complaints about waiting times in the office, appointment availability, participating provider demeanor and behavior, adequacy of facilities, the primary care physician (PCP) transfer process, delay of payment, or other service-related issues. Requests for reconsideration of an initial determination related to covered benefits are subject to the Medicare appeals process. Participating providers are required to adhere to Health Net's appeals and grievance procedures as outlined in Title 42 of the Code of the Federal Regulations (CFR) section 422.562.
The fact that a member submits a grievance or complaint to Health Net or to the PPG must not affect in any way the manner in which the member is treated by the PPG or receives services from participating providers. Members have the right to express dissatisfaction or concern and to expect prompt resolution without fear of retaliation or adverse effect on the care they receive.
A member who is dissatisfied or has a grievance may contact the Medicare Programs Member Services Department with an oral request or submit a written grievance to the Medicare Advantage Appeals and Grievances Department. Appeal requests must be submitted in writing unless the request is for an expedited appeal.
The member must include all pertinent information from his or her Health Net identification (ID) card and the details and circumstances of his or her concerns. Health Net acknowledges receipt of the request to the member within five business days, reviews the grievance and mails written notification to the member advising of the resolution of the grievance no later than 30 calendar days after receipt of the oral or written grievance. If a grievance cannot be resolved within 30 calendar days and a 14-day extension is needed, a letter that includes the reason for the extension is mailed to the member no later than 30 days after receipt of the oral or written grievance.
Health Net Medicare Advantage (MA) members may obtain additional information on member grievance procedures in their Evidence of Coverage (EOC).
Members are expected to use Health Net's grievance procedures first to attempt to resolve any dissatisfaction. If the grievance has been pending for at least 30 days with no response from Health Net, or the grievance was not satisfactorily resolved by Health Net, the member may seek assistance from the Centers for Medicare & Medicaid Services (CMS). Participating providers may assist the member in submitting a complaint to CMS for resolution and may advocate the member's position to CMS. No participating provider can be sanctioned in any way by Health Net or a participating physician group (PPG) for providing such assistance or advocacy.
CMS requires that the following note be placed in all correspondence pertaining to quality of care grievance cases:
Please note that you may also file a written grievance with the Quality Improvement Organization (QIO) designated for the state of California. Providers and health care experts at the QIO review quality of care complaints made by Medicare members regarding coverage. Contact the QIO for additional information about quality of care grievances.