CurrentHealth NetPolicy N/A

Appeals, Grievances, and Independent Medical Review processes for dental plan members

Governs how Health Net dental members may file appeals, grievances, expedited (urgent) appeals, requests for independent medical review (IMR), and state-level hearings under Knox-Keene; describes timelines, methods to submit, and member rights. Applies to members in California (Knox-Keene programs).

Policy Summary

PayerHealth Net

PolicyAppeals, Grievances, and Independent Medical Review processes for dental plan members

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionMembers may submit an appeal by phone, mail, fax, or electronically (Health Net Dental phone: 1-833-493-0428).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystimeframe members have to appeal from date of action notice

10 daysrecommended timeframe to request appeal

30 daysstandard response time for non‑expedited appeals

72 hoursexpedited decision timeframe

90 daysstate hearing decision timeframe

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Appeals, Expedited Appeals, IMR, and State Hearings

Appeals and external review procedures

Covered when ALL of the following steps and conditions are met:

ALL of the following

ALL of the following
- Member or authorized representative may submit an appeal by phone, mail, fax, or online; Health Net Dental phone: 1-833-493-0428; mailing and fax addresses for Appeals and Grievances Dept provided.
ALL of the following
- Options: Member generally has 60 days from date of action notice to file an appeal.
- To obtain 'continuation of benefits' (timely process) while appeal is pending, member must request the appeal within 10 days of the action notice or before the plan's effective date of change; if member misses the 10-day window they still have 60 days to appeal but may not receive continuation of benefits.
ALL of the following
- Standard (non‑expedited) appeals: written response sent within 30 days; member receives written notice of decision.
ALL of the following
- Member may request an expedited appeal if waiting the standard 30 days could seriously affect the member's health or ability to obtain or retain major bodily function; for expedited appeals the plan must attempt to notify and provide a decision as soon as possible and provide a decision within 72 hours when applicable.
ALL of the following
- If dissatisfied after internal appeals or in qualifying situations, member may request an Independent Medical Review (IMR) through the California Department of Managed Health Care (DMHC); DMHC determines eligibility for IMR and provides an impartial review of medical necessity or treatment disputes.
- Members who disagree with plan decisions may request a state hearing (administrative hearing); the plan may take up to 90 days to issue a decision on a formal hearing request but the hearing may be expedited if waiting would harm the member's health.
Exceptions to exhausting internal appeals (may proceed directly to external review)
- Member may request IMR or a state hearing without completing internal appeals in specific circumstances, including: plan errors affecting member rights, failure to provide action notices in the member's preferred language, failure to provide timely written decision within 30 days, errors in the written decision, or failure to respond to an appeal within required timeframes (including 72‑hour failures for urgent matters).
ALL of the following
- Member is not responsible for fees for IMR or state hearing; translation, TDD/TTY, and disability accommodations are provided at no cost. Contact details and helplines (including DMHC numbers and TDD) are available to assist members; free legal help (e.g., Legal Services) may be available for Knox‑Keene programs.

ALL of the following

When requesting expedited review or external review, members must explain how waiting the standard time (e.g., 30 or 90 days) would affect health, life, or major bodily function; procedures and forms for IMR and expedited hearings are available from DMHC, including phone numbers and web resources.

Timelines and Code Notes

No codes specifiedmixed

Appeal submission timing threshold

Appeal filing deadlineMembers have 60 days from the date they receive the action notice to file an appeal.

Recommended timing to preserve 'timely process'Members are advised to request the appeal within 10 days of the action notice so the plan will continue to provide disputed services during the appeal processing period.

Effect of missing 10‑day recommendationIf the member misses the 10‑day window but files within 60 days, the appeal is still allowed but the member may not continue receiving disputed services pending the appeal decision.

How to File Appeals, IMR & State Hearing Requests

Documentation Required

How to file an appeal (phone, mail, fax, electronic)

Members or their authorized representatives may submit an appeal by phone, mail, fax, or electronically. For phone submissions contact Health Net Dental at 1-833-493-0428 (available 8:00 a.m. to 5:00 p.m.). Mail appeals to Appeals and Grievances Department, P.O. Box 10348, Van Nuys, CA 91410-0348. Fax appeals to 1-877-713-6189. Providers’ offices may obtain and assist members with the appeal form; the plan also makes the form available online.

Phone: Health Net Dental 1-833-493-0428 (8:00 a.m. to 5:00 p.m.)
Mail: Appeals and Grievances Department, P.O. Box 10348, Van Nuys, CA 91410-0348
Fax: 1-877-713-6189
Electronic: appeal form available via the Health Net website; provider office can supply the form

Prior Authorization

Requests for IMR and state hearing — eligibility and next steps

Key Terms

Expedited appeal (urgent appeal)

DefinitionAn expedited (urgent) appeal is a request for faster review when waiting the standard response time could seriously affect the member's health.

When to requestMembers may request an expedited appeal if a 30‑day wait for a standard appeal decision would affect their health or if the situation involves urgent care needs.

Decision timeframeFor expedited appeals, the plan must make reasonable efforts to notify the member as soon as possible and provide a decision within 72 hours when applicable.

Independent Medical Review (IMR)

DefinitionIndependent Medical Review (IMR) is an external, impartial review administered by the California Department of Managed Health Care (DMHC) for qualifying disputes over medical necessity or treatment decisions.

Role of DMHC IMR