Appeals and Grievances |

Appeals and Grievances

 

Your satisfaction is our priority – so if you are having a problem getting the care or services you desire, we want to talk with you. Please call us and we will do everything we can to resolve your concern. If after we talk you are not satisfied; please reference the information below regarding your appeals and grievances rights.


 

Chapter 9 in your Evidence of Coverage includes the process and more information on how to file a reconsideration/redetermination (appeal) or complaint/grievance. Visit the Plan Materials and Forms page to view your plan’s Evidence of Coverage.

For process or status questions, please contact Member Services. 

Appointing a Representative – Instructions & Form

People who want to represent a member can be appointed or authorized by the member.

A member can authorize anyone (like a relative, friend, advocate, an attorney, or a doctor) to act as his or her representative and file an appeal on his or her behalf.

A representative (or surrogate) can also be authorized by the court or act on behalf of the member in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.

How to authorize a representative:

  • The member must sign, date, and complete a representative form.
  • The person acting on behalf of the member must sign, date and complete the same form.
  • Print and complete the Appointment of Representative form. If a member is incapacitated or legally incompetent a surrogate is not required to submit an Appointment of Representative Form. The surrogate will need to give Health Net of California copies of the legal papers supporting his or her status as the member’s authorized representative. Health Net of California requires a copy of the completed and signed Appointment of Representative Form to process an appeal filed by the member’s representative. The form will be valid during the entire appeal process. The Appointment of Representative Form is valid for one year from the date indicated on the form. A member can revoke the authorization at any time.

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Health Net of California

To obtain an aggregate number of Health Net of California grievances, appeals and exceptions, please call Member Services.

For help with complaints, grievances, and information requests, you can contact The Office of the Medicare Ombudsman (OMO). (By clicking on this link you will be leaving the Health Net Medicare Advantage for California website.)

To file a complaint directly with CMS – https://www.medicare.gov/MedicareComplaintForm/home.aspx (By clicking on this link you will be leaving the Health Net Medicare Advantage for California website.)

Contact Member Services. We are here to help!