CMS claims dispute resolution — original determination upheld
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Describes the Health Net National process and notice for upholding an original Medicare claim determination and how providers may request further review; applies to provider disputes submitted to Health Net National regarding CMS claims.
No material clinical or coverage changes in this revision.
Reasons the Original Determination Was Upheld
Reasons for upholding determination
Stance and reasons for upholding the original claim decision:
ALL of the following
Reason(s) for upholding
- Medicare rate paid at Area XX YEAR; and no additional amount is due.
- Additional information requested on Month date, year was never received.
- Other (free-text reason may be provided).
ALL of the following
- This dispute process is now closed; for additional information contact the specified entity and reference the claim/tracking/document number.
- Provider may request an additional decision by submitting a written request to: Medicare Provider Disputes PO Box 9030 Farmington, MO 63640-9030. Health Net must receive the written request within 180 days from the date of this notification.
ALL of the following
- Original claim determination upheld.
How to Request an Additional Decision
Request an additional decision (written request required)
You have the right to request an additional decision from Health Net. Submit a written request that references the claim/tracking/document number and forward all information regarding the claim to the address below. Health Net must receive the written request within 180 days from the date of this notification.
- Mail written request and all claim information to: Medicare Provider Disputes, PO Box 9030, Farmington, MO 63640-9030.
- Include the [Claim, tracking, document] number when contacting the plan or sending the request.
- Written request must be received by Health Net within 180 days from the date of notification.
Key Determination Definitions
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