While it is easy to let a Health Net Medi-Cal denial derail your life, you must speak to a knowledgeable attorney who has spent his or her career fighting big insurance companies—and winning. Of course, it is disheartening to receive a claim denial for a procedure, test, prescription drug, or medical device. That does not have to be the end of the story. Attorney Scott Glovsky helps people in similar situations every single day. At the beginning of his career, Scott worked for the other side. This gives him a unique perspective, allowing him to anticipate what big insurance companies will do, and allowing him to effectively counter their moves. Don’t feel as though you have no options following a Health Net Medi-Cal denial—speak to attorney Scott Glovsky today.
What Are Medi-Cal Plans?
As of 2023 about 15.3 million people—almost 40 percent of the state’s population—are enrolled in Medi-Cal. At the local level, County human services departments administer Medi-Cal. About 80 percent of those enrolled in Medi-Cal fall under a managed care plan—like an HMO—while the remaining 20 percent use a fee-for-service system when they access healthcare. Your household income, health issues, and/or age will determine whether or not you qualify for Medi-Cal health insurance. The state of California was able to offer health insurance to a larger number of people following the passage of the Affordable Care Act.
Medi-Cal provides the “typical” services that most health insurance companies provide, including access to physicians, hospitals, clinics, prescription drugs, labs, and vision and hearing care. Individual Medi-Cal benefits will depend on how you qualify for Medi-Cal. Full-scope Medi-Cal, means you qualify for all Medi-Cal coverage. Partial-scope Medi-Cal means only some services are covered. The county you live in will determine what plan you will fall under, including Anthem Blue Cross, Kaiser Permanente, Molina, Health Net, Promise, and more.
What Counties Offer Health Net Medi-Cal Managed Care Plans?
Health Net offers Medi-Cal Managed Care Plans in Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties. Health Net subcontracts as a plan partner in Fresno, Imperial, Kings, and Madera counties. Health Net subcontracts with Molina as a plan partner in Los Angeles. In this case, Molina is the subcontractor but doesn’t have a contract directly with the Department of Health Care Services in LA County.
Do Health Net Managed Care Plans Work with Independent Physician Associations (IPA)?
Health Net Medi-Cal Managed Care plans work together with IPAs. Independent Practice Associations (AKA Independent Physician Associations or Independent Provider Associations) are independent medical groups with their own practices and may also include urgent care clinics, hospitals, imaging centers, etc. When an insurance company works with an IPA, it usually transfers responsibility for approving and denying medical care to the IPA. Learn more about this relationship.
As of May 2024, Health Net works with nearly 1,700 medical groups in California including many IPAs such as Preferred IPA of California and Sequoia Health IPA.
Health Net Insurance Provider and Its Medi-Cal Plans
Health Net has built a high-quality network of doctors over the past two decades. Health Net has plans and services that cover individuals and families through every stage of their lives—and health. As a California company, Health Net supports its local communities with health screenings at local health events and community centers, as well as no-cost health education classes. All traditional health services, including preventative and wellness services, hospitalization, mental health assistance, prescription drug and laboratory services, specialist care, and much more.
What Types of Services Might Health Net Deny?
Receiving a Health Net Medi-Cal managed care denial for a procedure or prescription drug your doctor feels is important to your health can be difficult. While any health insurer can issue a denial for services or prescription drugs, denials are more likely when the procedure or drug is expensive. Of course, in some cases, you could receive a Health Net Medi-Cal managed care denial for something as simple as a lack of information on the paperwork, an information error, or a failure to obtain pre-authorization when necessary. Other times, your Health Net Medi-Cal managed care denial letter may state that the procedure or prescription drug is “experimental,” “investigational,” or “not medically necessary.” These are usually “codes” for “too expensive.”
Improper, unreasonable, and bad-faith denials of coverage when you need a procedure or prescription drug can leave you feeling as though you have no options. Fortunately, you have options when receiving an unreasonable Health Net Medi-Cal managed care denial. As one of the largest insurers operating in California, Health Net Medi-Cal has more than three million enrollees yet has frequently been a company that issues unwarranted or bad faith denials. Included among the abuses Health Net has been accused of over the years are designing a database that undercompensates enrollees for out-of-network claims as well as failing to properly review applications, and then cancelling an enrollee’s plan after approval when a claim is made. Health Net Medi-Cal managed care denials have resulted in lawsuits and hefty fines.
What Steps Should You Take if Health Net Denies Your Medi-Cal Claim?
Medi-Cal is a state program that is overseen by the Department of Healthcare Services (DHCS). Health Net recommends that you begin with contacting its Member Services instead of filing an appeal form. If your Health Net Medi-Cal managed care denial was not the result of an error or insufficient information that can be corrected, you can appeal the denial. You have several ways to file the appeal, and this is the page where you can file an on-line appeal. It’s important not to give up hope, as there are two levels of appeals you can file to try and get the decision of the healthcare insurer reversed. If you are recovering from an illness or injury, a denial of treatment can add an extra layer of stress to your situation.
Your attorney can help you through the process by first reviewing your denial letter and getting a good understanding of why your claim was denied. If your denial was due to something that can be easily fixed, your attorney can help guide you to do that, then the claim can be resubmitted. Your claim denial letter from Health Net must include detailed information regarding why your claim was denied, as well as how long you have to appeal the decision—and how to appeal the decision.
If your attorney determines that the best way to get your Health Net Medi-Cal managed care denial reversed is through an appeal, you and/or your doctor can prepare an internal appeal. Your attorney may ask for a letter from your doctor that details all the reasons you need the denied treatment. An internal appeal is essentially asking Health Net Medi-Cal to take another look at the claim and reverse its initial decision. If your situation is an emergency, Health Net must answer your internal appeal within 72 hours. Health Net will respond with its decision called a “Notice of Action.”
If Health Net still denies your claim, you (with the help of your attorney) can file an external appeal. An external appeal asks a neutral third party to look at the facts of the case and approve your denied medical treatment. If the external appeal is successful, Health Net Medi-Cal must pay for the treatment, test, or prescription drug that it initially denied. Your Explanation of Benefits will give you more details regarding the external appeal process as well as contact details for the external reviewer.
Note that the appeal process is a little different for Medi-Cal Managed Care Plans than it is for other types of health insurance. Although you begin with an internal Health Net review, with Medi-Cal, you can call the County Welfare Department to discuss a complaint, submit a discrimination complaint, or request a Medi-Cal Fair Hearing. Health Net, like other Medi-Cal insurers, will determine to uphold or to reverse its denial.
How the Law Offices of Scott Glovsky Can Help With Health Net Medi-Cal Denials
When you choose attorney Scott Glovsky to assist you with your Health Net Medi-Cal managed care denial, you have taken an important first step toward a positive outcome. Scott and his legal team have empathy for your situation. Our firm has gone up against the biggest health insurance companies with very favorable results for our clients. Scott and his legal team are a cohesive force for each client. Scott is an award-winning Pasadena insurance bad faith lawyer and nationally recognized advocate. Your case will be approached with the knowledge and understanding that the outcome could affect the rest of your life, as well as the lives of your family members. Contact the Law Offices of Scott Glovsky today for justice you can count on.