Denied or Contested Claims
Health Net notifies the provider of service in writing of a denied or contested HMO, POS, AIM, and Healthy Families claim no later than 45 working days after receipt of the claim. PPO, EPO, Flex Net, and Medi-Cal claims are denied or contested within 30 working days. In addition, Health Net notifies professional providers within 24 hours of the determination that a claim is contested.
Date of contest or date of denial is the electronic mark or postmark date indicating the date when the contest or denial was transmitted electronically or mailed by U.S. mail.
A contested claim is one that Health Net cannot adjudicate or accurately determine liability because more information is needed from either the provider, the claimant or a third party.
Incomplete claims or claims that require additional information are contested in writing by Health Net in the form of a Remittance Advice (RA), which may in some circumstances be followed by additional written communication within the timeframes noted above. If Health Net needs additional information before the claim can be adjudicated, the necessary information must be submitted within 365 days of the date of the RA that reflects the contested claim, in order to have the claim considered by Health Net.
All denied and contested information is reflected on the RA for each claim. Separate letters of denial will not be sent out. However, supplemental notices describing the missing information that is needed will be sent to the provider within 24 hours of a determination to contest the claim, as well as 30 days thereafter, and again, 60 days after the determination if there is still no response to earlier notices.
Each RA includes instructions on how to submit the required information in order to complete the claim if Health Net has contested it. Each RA reflecting a denied, adjusted or contested claim includes instructions on the department to contact for general inquiries or how to file a provider dispute, including the procedures for obtaining provider dispute forms and the mailing address for submission of the dispute.