Appeals and Grievances – Employer Group Medicare Members

An "appeal" is the type of complaint you make when you want us to re-evaluate and change a decision we have made about what benefits are covered for you or what we will pay for a benefit. You need to file your appeal within 60 calendar days from the date on the coverage determination/organization determination notice (denial letter) you received. Health Net may accept an appeal or redetermination beyond 60 days if you show Health Net good cause for an extension.

To file a standard appeal, you must send a written request stating the nature of the complaint, giving dates, times, persons, places, etc. involved. Or you may complete the Medical Appeals & Grievance Department Request for Reconsideration form in place of a letter. Completion of this form is not required to file an appeal. Please include copies of any additional information that may be relevant to your appeal and mail, email or fax to the address(s) and/or fax number listed in the How to File section below.

How quickly we decide on your appeal depends on the type of appeal:

For a decision about payment for services you already received: After we receive your appeal, we have 60 calendar days to reconsider our decision. If we find in your favor, we must issue payment within 60 calendar days of the date of receipt of your appeal request.

For a standard decision about authorizing medical care: After we receive your appeal, we have up to 30 calendar days to make a decision, but will make it sooner if your health condition requires. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

For a decision about payment for Part D prescription drugs you already received: After we receive your appeal, we have 14 calendar days to make a decision. If we find in your favor, we have 30 days from the date of receipt of your appeal request to issue payment.

For a standard decision about Part D prescription drugs: After we receive your appeal, we have up to 7 calendar days to make a decision, but will make it sooner if your health condition requires.

In addition, you, any doctor, or your authorized representative can ask us to give you an expedited ("fast") reconsideration or appeal (rather than a "standard" appeal) about drugs or services that you have not already received, if you or your doctor believe that waiting for a standard appeal decision could seriously harm your health or your ability to function. If we give you an expedited ("fast") decision, we must make our reconsideration decision as expeditiously as your health condition might require, but no later than 72 hours of receiving your request. We may extend the timeframe by up to 14 calendar days (for medical appeals) if you request the extension, or if we justify a need for additional information and the delay is in your best interest. For an expedited ("fast") appeal, contact us by telephone or fax at the number listed in the How to File section below.

For denials of medical appeals: If we deny any part of your medical appeal, your case will automatically be forwarded to an independent review organization, to review your case. This independent review organization contracts with the Federal government and is not part of our Plan.

For denials of Part D appeals: If we deny any part of your Part D appeal, you or your appointed representative can mail or fax your written appeal request to the independent review organization to the address and / or fax number listed below:

MAXIMUS Federal Services
3750 Monroe Ave., Suite #703
Pittsford, NY 14534-1302

Toll-free fax number for enrollees: 1-866-825-9507
Fax number for enrollees: (585) 425-5301

The independent reviewer will review our decision. If any of the medical care or service you requested is still denied, you can appeal to an administrative law judge (ALJ) if the value of your appeal meets the minimum requirement. You will be notified of your appeal rights if this happens.

There is another special type of appeal that applies only when coverage will end for SNF (Skilled Nursing Facility), HHA (Home Health Agency) or CORF (Comprehensive Outpatient Rehabilitation Facilities) services. If you think your coverage is ending too soon, you can appeal directly and immediately to Livanta, which is the Quality Improvement Organization in the state of California. See "How to File" section below to contact Livanta.

• If you get the notice 2 days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice.
• If you get the notice and you have more than 2 days before your coverage ends, then you must make your request no later than noon of the day before the date that your Medicare coverage ends.

Important Appeals Information

If you have questions about Appeal procedures you may refer to the applicable sections of the Evidence of Coverage (EOC) for your respective plan as outlined below, or you can call Health Net Customer Service at the phone number listed in the How to File section below.

If you want to inquire about the status of an appeal, please call Health Net Customer Service at the phone number listed in the How to File section below.

As a Health Net member, you have the right to request information on the following:

• Additional information from Medicare by calling
  1-800-MEDICARE (1-800-633-4227; TTY/TDD Hearing Impaired 1-877-486-2048), which is the national Medicare help line, 24 hours a day, 7 days a week.
• To obtain a total number of Health Net's grievances, appeals and exceptions, please call Health Net Customer Service at the phone number listed in the How to File section below.

Appointing a Representative

• If you would like to appoint a representative to act on your behalf, additional information is available on our Appointing a Representative page.

A grievance is any complaint or dispute other than an organization determination, expressing dissatisfaction with the manner in which Health Net Medicare Programs provides health care services. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office. You need to file your grievance within 60 calendar days after the event. Please note: For a complaint, Health Net can give you more time if you have a good reason for missing the deadline.

If you have a grievance, we encourage you to first call Health Net Customer Service at the number listed below. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the grievance procedure. There is no form required for filing a grievance. You may also submit your complaint in writing or via facsimile or email to Health Net at the address and/or fax number listed in the How to File section below.

We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request for the extension, or if we justify a need for additional information and the delay is in your best interest.

You are also entitled to a quick review of your complaint (expedited grievance) if you disagree with our decision in the following scenarios:

• If we deny your request for an expedited review of a request for medical care or a Part D drug
• If we deny your request for an expedited review of an appeal for denied services or a Part D drug
• If we decide an extension is needed to review your request for medical care
• If we decide an extension is needed to review your appeal of denied medical care

You may also submit your expedited grievance request orally, in writing or via facsimile or email to Health Net at the address and/or fax number listed in the How to File section below. We will quickly review your request and notify you of our decision as expeditiously as your health condition might require, but no later than 24 hours of receiving your complaint.

If you have questions about these grievance procedures you may refer to the applicable sections of the Evidence of Coverage (EOC) for your respective plan as outlined below, or you can call Health Net Customer Service at the phone number listed in the How to File section below.

If you want to inquire about the status of a grievance, please call Health Net Customer Service at the phone number listed in the How to File section below.

As a Health Net member, you have the right to:

• Tell Medicare about your complaint by calling 1-800-MEDICARE (1-800-633-4227; TTY/TDD Hearing Impaired 1-877-486-2048), which is the national Medicare help line, 24 hours a day, 7 days a week. Or you may fill out a Complaint Form.
• Obtain a total number of Health Net's complaints, appeals and exceptions; please call Health Net Customer Service at the phone number listed in the How to File section below.

For quality of care complaints, you may also complain to the Quality Improvement Organization (QIO)

Complaints concerning the quality of care received under Medicare may be acted upon by Health Net under the grievance process, by an independent organization called the QIO, or by both. For example, if a member believes he/she is being discharged from the hospital too soon, the member may file a complaint with the QIO in addition to or in lieu of a complaint filed under Health Net's grievance process. For any complaint filed with the QIO, Health Net will cooperate with the QIO in resolving the complaint.

How to file a quality of care complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. A member who files a quality of care grievance with a QIO is not required to file the grievance within a specific time period. Please see below in the 'How to File an Appeal or Grievance' section for specific contact information.

Appointing a Representative

• If you would like to appoint a representative to act on your behalf, additional information is available on our Appointing a Representative page.