Provider Claim Disputes & Redeterminations

Whenever possible, Health Net strives to informally resolve issues raised by providers at the time of the initial contact. If an issue cannot be resolved informally by a customer contact associate, Health Net offers its providers a two-level internal redetermination process.

Provider Disputes & Redeterminations

A 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. A provider dispute is accepted when received within the Provider Participation Agreement (PPA) appeal time limit. Disputes and appeals received after the PPA time limit is exhausted are not considered. Referring providers with no financial liability have no dispute or appeal rights unless there are extenuating circumstances such as lack of patient insurance information.

If a referring provider chooses to co-author a dispute or appeal with the rendering provider, Health Net accepts the dispute or appeal.

A 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. Note that a provider's first written communication is considered a dispute even if appeal is written on the communication. The following four exceptions automatically become member appeals:

Medical necessity claim denials (when there is a member balance)
Experimental and investigational claim denials
Benefit exhaustion claim denials
Submission of an appeal on behalf of a member

When one of the above four situations occurs, providers must follow the member appeals process. Refer to the Member Appeals topic for more information.

Provider submission timelines begin from the date of the Remittance Advice (RA). Providers should refer to their Health Net PPA for specific submission timelines. 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).

Health Net responds to provider disputes within 30 calendar days of receipt and notifies providers if resolution requires more than 30 days. Notices of overturns of partial payment or payment denial disputes are via the RA on the adjusted claim. When a provider submits a payment dispute in writing and Health Net upholds the previous decision, Health Net notifies the provider in writing. When a provider submits a verbal dispute and Health Net upholds the decision, Health Net responds to the provider verbally.

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.

General Appeal Process

A provider appeal is defined as all written communication with Health Net that clearly indicates the communication is an appeal. Participating providers must have exhausted the dispute process. As in disputes, exceptions that automatically become member appeals are:

Medical necessity claims denials (when there is a member balance)
Experimental and investigational claims denials
Benefit exhaustion claim denials
Submission of an appeal on behalf of a member

For member appeals, providers must follow the member appeals process.

Appeal submission timelines may vary by PPA. Providers should refer to their PPA for this information. Provider appeals must be submitted in writing to Health Net as follows:

Submit a written request indicating it is an appeal
Submit a written request indicating it is related to an experimental or investigational issue, medical necessity, benefit exhaustion, or on behalf of the member

Providers can use the Provider Dispute Request Form (PDF), but this is not required.

For 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.

Timely Filing Appeal Process

Providers wanting to dispute or appeal timely filing claim denials must include supporting proof of timely filing as follows:

Electronic Claim Submission:

Clearinghouse receipt that must include Health Net acceptance data
Screen print showing original Health Net billing
Member billing, if applicable

Paper Claim Submission:

All supporting documentation regarding the original claim submission as well as Health Net insurance information
Computer screen print showing Health Net was billed; Health Net's name and billing information must be indicated on the screen print
If a provider uses an internal key code to represent carriers billed, the provider must submit proof that the key code used represents Health Net, including a copy of the provider office internal key code list
Provider must include the billing address and date of original submission
Computer screen print showing original Health Net billing
Member billing, if applicable
For coordination of benefits (COB) accounts, billing to primary carrier or denial from other insurance

Claim Previously Submitted via Facsimile

For claims previously submitted via facsimile to our Customer Service department, include the facsimile confirmation sheet indicating the documents were received

Claim Never Submitted:

Detailed explanation; for example, no insurance information provided by member; incorrect insurance information provided by member
Submit timely filing documentation to Health Net of Oregon

A Provider Appeals Committee made up of clinicians and various Health Net staff review appeal requests. Health Net responds to provider appeals in writing on both overturns and upholds within 30 calendar days of receipt, and notifies providers of any delays if a resolution requires more than 30 days.

Providers who are not satisfied with an appeal decision may request further resolution pursuant to the terms of their PPA