HOW TO FILE GRIEVANCES AND APPEALS
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This material is being provided to you in accordance with Arizona’s Health Care Appeals Law. If you
have any questions about this Law or the appeals process, you may call Ambetter from Health Net at
888-926-5057 (TTY 800-977-6757 for the hearing impaired) or you may call the Consumer Services
Division of the Arizona Department of Insurance at 602-364-2499 or 800-325-2548 (outside the Metro
Phoenix area).
YOUR SATISFACTION IS OUR CONCERN
At Ambetter from Health Net, we want you to be pleased with the quality of care and service you receive. Surveys show that
most of our members are satisfied and many stay with us year after year. We hope you are one of those members. If not, we
want to hear from you so we can improve.
Anytime you have a concern about the quality of care you receive, the level of our service or any other aspect of your health
plan- we want to know. Call us toll free at 888-926-5057 (TTY 800-977-6757 for the hearing impaired). Many times, a single
phone call to our Customer Contact Center staff can make things right.
In addition to calling our Customer Contact Center, there are other avenues for you to use if you do not agree with a decision
made by us or by one of the health care professionals who work with us. Like you, we want to be sure the appropriate decisions
are made regarding your medical care and that you receive the benefits your health plan covers.
SHOULD YOU FILE A GRIEVANCE OR AN APPEAL?
Grievance
You initiate a grievance when you are not satisfied with the quality of care or service you are receiving.
Appeal
You file an appeal in response to a denial received from Ambetter from Health Net. This could be a denial of coverage for
requested medical care or for a claim you filed for care already received.
HOW TO GET STARTED
Phone
You can initiate either the appeal or grievance process by phone. Contact our Customer Contact Center Monday through
Friday from 7 a.m. to 6 p.m. at 888-926-5057 (TTY 800-977-6757 for the hearing impaired).
Mail
You can mail a written appeal or grievance to:
Ambetter from Health Net
Attn: Appeals & Grievances Department
P.O. Box 277610
Sacramento, CA 95827
Fax
You may also fax a written appeal to Ambetter from Health Net Appeals and Grievances Department at 877-615-7734. Please
write “Attn: A&G Manager” on your cover page.
THE GRIEVANCE PROCESS
A grievance is the first step you take to tell us that we are not meeting your expectations. A grievance tells us that you are not
pleased with the quality of medical care or the service that you received. A grievance brings your concern to our attention.
We want you to let us know how we can improve any aspect of your medical care, preventive health benefits, customer service
or your understanding of your health plan. Call, write or fax your grievance to us. We will acknowledge receiving your
grievance within 5 business days. You will receive a decision within 30 calendar days. Occasionally, Ambetter from Health
Net may take an extra 14 calendar days to receive and review information before we send you our decision. Every grievance
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about the quality of medical care is taken seriously. That’s why we have a Quality Improvement Department for investigation
and follow-up with the doctor or facility that provided the care.
THE APPEAL PROCESS
An appeal asks us to review our denial of your request for coverage of medical care or claim for reimbursement. Your
appeal goes to people who have not reviewed your case before. In many cases, you can call, write or fax your request to start
the appeal process.
You’ll want to know that medical information is reviewed by physicians at every level – from your primary care physician, to a
referral specialist, other doctors in the medical group and our medical directors. The type of care requested must be medically
necessary – and it must be a service or treatment that is covered by your health plan.
In many cases, you can present the specifics of your initial appeal by phone.
These are the levels for our appeal process. Not every appeal is eligible for all levels of review. Our levels are:
Formal Appeal
External Independent Review
Expedited Appeal (2
nd
Level)
Expedited External Independent Review
You are entitled to receive upon request, and free of charge, access to and copies of document and records, including the
benefit provision, guideline, protocol and other criteria we used to make a denial determination. Make your request in writing
and be sure to include the address where you want your records sent.
You have the right to representation at all levels of appeal by anyone you choose to act on your behalf. To exercise this right,
an appointment of representative form should be provided to us along with your request for appeal. Nothing herein limits a
member’s right to pursue any appropriate legal action, nor shall it act as a waiver of any defense by Ambetter from Health Net.
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Formal Appeal
This is the first step in the process if you are an Individual and Family Plan member. You have up to 180 days after date of the
denial to request a Formal Appeal. Ambetter from Health Net’s Appeals and Grievances Department will oversee the
processing of your appeal. Include detailed information from you and your doctor to support your request for care or payment
of a claim. We will send you and your doctor an acknowledgment letter, along with another copy of our “How to File
Grievances and Appeals” document, within 5 business days after receiving your request. We will review the information
provided, make a decision and notify you and your doctor, along with criteria used and any clinical reasons for the decision,
within 30 calendar days for pre-service appeals and within 60 calendar days for claims or post service appeals. We may
overturn our earlier denial and approve specified medical services or pay the claim. We also may uphold the original decision.
In that case, you can take the final step in the appeals process – request an External Independent Review.
However, if your appeal is related to the enforcement of or adjustments to a deductible, copayment or coinsurance requirement;
the formal appeal is the last level of review. Under Arizona law, those appeals are not eligible for External Independent
Review.
External Independent Review
After you have filed a Formal Appeal and if We have upheld Our earlier denial, the next step is an External Independent
Review. This is the final level of appeal for both Individual and Family Plan members and goes beyond us to include outside
reviewers. You do not have any financial responsibility for the costs of this review. You must send your request in writing to
the Ambetter from Health Net Appeals and Grievances Department within 60 calendar days after you receive our decision on
your Formal Appeal. The Ambetter from Health Net Appeals and Grievances Department will oversee the processing of your
appeal. Within 5 business days, We will send to you, your doctor and the Arizona Department of Insurance (ADOI) an
acknowledgment letter that We have received your request. This level of appeal has two options based on the reason for the
original denial:
Is the Care Medically Necessary?
If your issue is based upon a determination of whether the services are medically necessity, as defined in your policy, We will
forward your case to the Arizona Department of Insurance within 5 business days. You do not have any financial
responsibility for the costs of this review. The Arizona Department of Insurance will submit your request, with all supporting
documentation, to the external medical reviewer within 5 business days. The external medical reviewer must notify the
Arizona Department of Insurance of its decision within 21 business days. After receiving the external medical reviewer’s
determination, the Arizona Department of Insurance will mail the decision to you, your Provider and us within 5 business
days.
Is the Care a Covered Benefit?
If your appeal is based upon a determination of whether certain services are covered under your policy, the Arizona
Department of Insurance will make a determination as to whether the requested service or the claim is covered. Your request
and your records will be forwarded to the Arizona Department of Insurance within 5 business days. You do not have any
financial responsibility for the costs of this review. The Arizona Department of Insurance has to make a determination and mail
the decision to you, your Provider, and us within 15 business days. If the Arizona Department of Insurance cannot make a
determination on an issue of benefit Coverage, your request and the supporting documentation will be sent to an independent
reviewer organization within 5 business days. The external medical reviewer must notify the Arizona Department of Insurance
of its decision within 21 business days. After receiving the external medical reviewer’s determination, the Arizona Department
of Insurance will mail the decision to you, your Provider and us within 5 business days.
The External Independent Review is the final step in our appeal process. (You may qualify for an Expedited External
Independent Review. The criteria for this level are outlined below.)
Expedited Appeal Review
An Expedited Appeal Review is used when we have denied coverage for a medical service and the treating provider verifies
that the time period for the Formal Appeal process could cause a significant negative change in the insured’s medical
condition. You can initiate the Expedited Appeal Review by mailing, phoning or faxing your request to Ambetter from Health
Net’s Appeals and Grievances Department. The Ambetter from Health Net’s Appeals and Grievances Department will oversee
the processing of your appeal. Once we receive the necessary information, we will respond within 72 hours. We may overturn
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the original decision and approve specified medical services. We also may uphold the original denial. In that case, we will
provide telephonic and written notification of the adverse decision to you and your treating provider. Upon notification that the
original denial was upheld, you may ask for the next level of review – the Expedited External Independent Review.
Expedited External Independent Review
After you have filed an Expedited Appeal Review Request and if we have upheld our earlier denial, the next step is an
Expedited External Independent Review. This is the final level of appeal and goes beyond Ambetter from Health Net to include
outside reviewers. You do not have any financial responsibility for the costs of this review. You must send your request in
writing to Ambetter from Health Net’s Appeals and Grievances Department within 5 business days after you receive our
decision on your Expedited Appeal Review. Within 72 hours, we will send to you an acknowledgement letter that we have
received your request and forward your case to the Arizona Department of Insurance. This level of appeal has two options
based on the reason for the original denial. It is determined based on whether the care is medically necessary or if the care is a
covered benefit.
Is the Care Medically Necessary?
If we have denied your request for care or your claim because it was not medically necessary, then other medical professionals
will review your case. Within 2 business days, The Arizona Department of Insurance (ADOI) will choose an Independent
Review Organization (IRO) and will forward the necessary documentation for their review. Ambetter from Health Net will
give the ADOI your medical records, a description of the criteria and clinical reasons used when making its decision, the name
and credentials of the provider who reviewed the appeal and any other supporting information. Upon receipt of all required
documentation, the IRO has 5 business days to issue a decision. Upon receipt of the decision, the ADOI has 1 business day to
transmit the decision to us, the Insurer, and the treating provider.
Is the Care a Covered Benefit?
If we have determined the care you requested or your claim for services received was not covered by your health plan, your
case will be sent to the Arizona Department of Insurance (ADOI). At this point in the appeal process, the ADOI can direct us to
approve coverage for specified medical care or pay the claim or it can uphold our original decision. Within 2 business days
upon receipt of all required information, the ADOI will issue a decision and transmit it to us, the Insured, and the treating
provider.
The ADOI can also determine that the type of care requested is covered by your health plan and may elect to submit the case
to an independent reviewer to decide if the care is medically necessary.
The Expedited External Independent Review is the final step in our Expedited Appeal process. There is no further appeal
for denied services or claims.
OTHER APPEAL & GRIEVANCE INFORMATION
Getting Your Medical Records
Under Arizona law, you and your health care decision-maker are entitled to a copy of your medical records from any health
care professional that has treated you. Make your request in writing and be sure to include the address where you want your
records sent. In some cases, your records will be sent only to the medical professional that you have designated.
Confidential Medical Information
Your medical records are confidential. They are used only as needed to make decisions about your care or for any appeals you
may file. During an appeal, we may release some portions of your medical records to the people who are reviewing your case.
Mailing Documents
We want to be sure our response reaches you. Please confirm that Ambetter from Health Net has your current mailing
address in our records because that is where documents will be sent. We consider information mailed to you to be received
on the fifth business day.
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The Role of the Director of the Arizona Department of Insurance
The Director of the ADOI will oversee this appeals process. The Director will maintain a copy of each health plan’s utilization
review policy; receive, process and act on requests from health plans for External Independent Review; review and enforce or
overturn the decisions of the health plans; and file appropriate reports with the Arizona Legislature. When necessary, the
Director must transmit appeal records to the Superior Court or the Office of Administrative Hearings and issue final
administrative decisions.
Questions
If you have questions or need assistance, please call our Customer Contact Center at 888-926-5057 (TTY 800-977-6757 for
the hearing impaired).
You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out
what may be available is to contact the Arizona Department of Insurance’s Consumer Division at 602-364-2499 or
800-325-2548 (outside the Metro Phoenix area).
In Arizona, Health Net of Arizona, Inc. underwrites benefits for HMO plans. Health Net of Arizona, Inc. is a subsidiary of
Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks
remain the property of their respective companies. All rights reserved.
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HEALTH CARE APPEAL REQUEST FORM
You may use this form to tell your insurer you want to appeal a denial decision.
Insured Member’s Name
Member ID #
Name of representative pursuing appeal, if different from above
Mailing Address
Phone #
City
State
Zip Code
Type of Denial: Denied Claim Denied Service Not Yet Received
Name of Insurer that denied the claim/service:
If you are appealing your insurer’s decision to deny a service you have not yet received, will a 30 to 60 day
delay in receiving the service likely cause a significant negative change in your health? If your answer is
“Yes,” you may be entitled to an expedited appeal. Your treating provider must sign and send a certification
and documentation supporting the need for an expedited appeal.
What decision are you appealing?
(Explain what you want your insurer to authorize or pay for.)
Explain why you believe the claim or service should be covered:
(Attach additional sheets of paper, if needed.)
If you have questions about the appeals process or need help to prepare your appeal, you may call the
Department of Insurance Consumer Assistance number (602) 364-2499 or (800) 325-2548, or Ambetter from
Health Net at (888)-926-5057 (TTY (800) 977-6757 for the hearing impaired). Make sure to attach everything
that shows why you believe your insurer should cover your claim or authorize a service
including: □ Medical records □ Supporting documentation (letter from your doctor, brochures, notes, receipts, etc.)
**Also attach the certification from your treating provider if you are seeking expedited review.
Signature of insured or authorized representative
Date
You can mail this form to: Ambetter from Health Net Appeals and Grievances Department, Attn: Appeals & Grievances, P.O.
Box 277610, Sacramento, CA 95827-7610.
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PROVIDER CERTIFICATION FORM FOR EXPEDITED MEDICAL REVIEWS
(You and your provider may use this form when requesting an expedited appeal)
A patient who is denied authorization for a covered service is entitled to an expedited appeal if the treating provider
certifies and provides supporting documentation that the time period for the standard appeal process (about 60
calendar days) “is likely to cause a significant negative change in the member's medical condition at issue.”
PROVIDER INFORMATION
Treating Physician/Provider
Phone #
FAX #
Address
City
State
Zip Code
PATIENT INFORMATION
Patient’s Name
Member ID #
Phone #
Address
City
State
Zip Code
INSURER INFORMATION
Insurer Name
Phone #
FAX#
Address
City
State
Zip Code
Is the appeal for a service that the patient has already received? Yes No
If “Yes,” the patient must pursue the standard appeals process and cannot use the expedited appeals
process
If “No,” continue with this form.
What service denial is the patient appealing?
Explain why you believe the patient needs the requested service and why the time for the standard appeal
Process will harm the patient.
Attach additional sheets if needed, and include: Medical records Supporting documentation
If you have any questions about the appeals process or need help regarding this certification, you may call the
Department of Insurance Consumer Assistance number (602) 364-2499 or (800) 325-2548. You may also call
Ambetter from Health Net of Arizona at (888)-926-5057 (TTY (800) 977-6757).
I certify, as the patient’s treating provider, that delaying the patient’s care for the time period needed for the informal
reconsideration and formal appeal processes (about 60 calendar days) is likely to cause a significant negative
change in the patient’s medical condition at issue.
Provider’s Signature
Date
***** Please fax signed, completed form and supporting medical records to: *****
Ambetter from Health Net Appeals and Grievance 877-615-7734
