![]() ![]() See "How to File" section below to contact Livanta. 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. 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. You will be notified of your appeal rights if this happens. 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. The independent reviewer will review our decision. This independent review organization contracts with the Federal government and is not part of our Plan.įor 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: For an expedited ("fast") appeal, contact us by telephone or fax at the number listed in the How to File section below.įor 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. 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. 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. 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 find in your favor, we have 30 days from the date of receipt of your appeal request to issue payment.įor 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. 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.įor 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 must issue payment within 60 calendar days of the date of receipt of your appeal request.įor 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. How quickly we decide on your appeal depends on the type of appeal:įor a decision about payment for services you already received: After we receive your appeal, we have 60 calendar days to reconsider our decision. 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. Completion of this form is not required to file an appeal. Or you may complete the Medical Appeals & Grievance Department Request for Reconsideration form in place of a letter. To file a standard appeal, you must send a written request stating the nature of the complaint, giving dates, times, persons, places, etc. Health Net may accept an appeal or redetermination beyond 60 days if you show Health Net good cause for an extension. You need to file your appeal within 60 calendar days from the date on the coverage determination/organization determination notice (denial letter) you received. 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. ![]()
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