All supporting documentation regarding the original claim submission as well as Health Net insurance information.Screen print showing original Health Net billing.Clearinghouse receipt that must include Health Net acceptance data.Providers wanting to dispute or appeal timely filing claim denials must include supporting proof of timely filing as follows: Providers can use the Provider Dispute Request Form (PDF), but this is not required.įor appeals with a clinical component, such as denied hospital days, services denied for lack of prior authorization and claims editing disallowed amounts, providers should submit supporting documentation, including a narrative describing the subject of the appeal, an operative report and medical records, as applicable. Submit a written request indicating it is related to an experimental or investigational issue, medical necessity, benefit exhaustion, or on behalf of the member.Submit a written request indicating it is an appeal.Provider appeals must be submitted in writing to Health Net as follows: Providers should refer to their PPA for this information. Experimental and investigational claims denialsįor member appeals, providers must follow the member appeals process.Īppeal submission timelines may vary by PPA.Medical necessity claims denials (when there is a member balance). As in disputes, exceptions that automatically become member appeals are: Participating providers must have exhausted the dispute process. General Appeal ProcessĪ provider appeal is defined as all written communication with Health Net that clearly indicates the communication is an appeal. Providers who are not satisfied with Health Net's first-level decision may request an appeal by following the instructions listed in the dispute uphold letter and submitting new or additional information not previously received or reviewed. When a provider submits a verbal dispute and Health Net upholds the decision, Health Net responds to the provider verbally. When a provider submits a payment dispute in writing and Health Net upholds the previous decision, Health Net notifies the provider in writing. Notices of overturns of partial payment or payment denial disputes are via the RA on the adjusted claim. Health Net responds to provider disputes within 30 calendar days of receipt and notifies providers if resolution requires more than 30 days. Providers can submit provider disputes to Health Net by telephone or in writing, and may choose, but are not required, to use the Provider Dispute Request Form (PDF). Providers should refer to their Health Net PPA for specific submission timelines. Provider submission timelines begin from the date of the Remittance Advice (RA). Refer to the Member Appeals topic for more information. When one of the above four situations occurs, providers must follow the member appeals process. Submission of an appeal on behalf of a member.Experimental and investigational claim denials.Medical necessity claim denials (when there is a member balance).The following four exceptions automatically become member appeals: Note that a provider's first written communication is considered a dispute even if appeal is written on the communication. If a referring provider chooses to co-author a dispute or appeal with the rendering provider, Health Net accepts the dispute or appeal.Ī provider dispute is also defined as any written communication with Health Net (for example, written correspondence, email and fax) that does not reference appeal in the request. Referring providers with no financial liability have no dispute or appeal rights unless there are extenuating circumstances such as lack of patient insurance information. Disputes and appeals received after the PPA time limit is exhausted are not considered. A provider dispute is accepted when received within the Provider Participation Agreement (PPA) appeal time limit. Provider Disputes & RedeterminationsĪ provider dispute is defined as any verbal or written communication between a provider and Health Net that includes seeking to overturn a partial payment or payment denial decision. If an issue cannot be resolved informally by a customer contact associate, Health Net offers its providers a two-level internal redetermination process. Whenever possible, Health Net strives to informally resolve issues raised by providers at the time of the initial contact.
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