Claims Dispute Resolution Process
Corrected Claims Submission
Clean claim resubmissions must be received no later than 12 months from the date of services or 12 months after the date of eligibility posting, whichever is later.
A corrected claim is one that may have been denied for:
- Needing additional information
- Incorrect date of service
- Timely filing
- Incorrect procedure code/modifier
- Age/gender, age/procedure
- Number of units
- Bill type
To resubmit a corrected EDI claim, the Claim Frequency code (3rd character in the bill type) in the 2300 loop CLM05-3 segment should be populated with a '7' to indicate replacement of previous claim. The original Health Net Access generated claim ID, if known, should be sent in the 2300 CLM loop with a REF segment with an F8 qualifier.
To resubmit on paper, corrected claims must be appropriately marked as such. For a UB04, the 3rd digit of the bill type in Box 4 should indicate a '7' as a replacement of previous claim. The Health Net Access generated claim ID in Box 65 labeled Payer Claim ID. For CMS1500 submission, the claim resubmission code in Box 22a should contain a '7' for replacement of previous of claim and the original Health Net Access generated claim ID should be sent in Box 22b labeled the Original Ref number.
Resubmitted paper claims must be sent to:
Health Net Access, Inc.
PO BOX 14095
Lexington, KY 40512
Health Net Access Provider Dispute Resolution Process
Providers should exhaust all authorized processing / resubmission procedures before filing a claim dispute with Health Net Access.
It is recommended that the provider follow these guidelines before filing a claim dispute:
If the provider has not received a Health Net Access Remittance Advice identifying the status of the claim, they should call the Provider Services Department at (888) 788-4408 to inquire whether the claim has been received, processed and it's status.
Providers should allow ample time following claim submission before inquiring about a claim. However, providers should inquire well before 6 months from the date of service because of the time frame for initial claim submission and for filing a claim dispute.
If a claim is pending status in Health Net Access' claim system, a claim dispute will not be investigated until the claim is paid or denied. A delay in processing a claim may be cause for Health Net Access to entertain a claim dispute on a pended claim provided all claim dispute deadlines are met.
If the provider has exhausted all authorized processing procedures, the provider has a right to request a provider State Fair Hearing to AHCCCS
Definition of a Provider Dispute
A provider dispute is a written notice from the provider to Health Net Access that:
- Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied or adjusted
- Challenges a request for reimbursement for an overpayment of a claim
- Seeks resolution of a billing determination
Provider Dispute Timeframe
Health Net Access accepts disputes if they are submitted no later than 12 months from the date of services, 12 months after the date of eligibility posting or within 60 days after the payment, denial or recoupment of a timely claim submission, whichever is later and as described above.
If the provider's Contractual Agreement provides for a dispute-filing deadline that is greater or less than 365 calendar days, this time frame continues to apply unless and until the contract is amended.
Submission of Provider Disputes
When submitting a provider dispute, a provider should utilize a Provider Dispute Resolution Request form. If the dispute is for multiple and substantially similar claims, a Provider Dispute Resolution Request Spreadsheet should be submitted along with the Provider Dispute Resolution Request form.
The provider's dispute must include the provider's name, ID number, contact information including telephone number, and the same number assigned to the original claim. Additional information required includes:
- If the dispute is regarding a claim or a request for reimbursement of an overpayment of a claim, the dispute must include a clear identification of the disputed item, the date of service, and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect
A provider dispute that is submitted on behalf of a member for services not billed or rendered and for which there is an authorization denial will be processed through the Member Appeals process, granted the member has authorized the provider to appeal on their behalf. When a provider submits a dispute on behalf of a member, the provider is assisting the member with his or her member appeal. The submission should be submitted through the Member Appeals & Grievances process.
If the provider dispute involves a member, the dispute must include the member's name, ID number, a clear explanation of the disputed item, the date of service, billed and paid amounts, and the provider's position. Health Net Access does not request providers to resubmit claim information or supporting documentation that was already previously submitted to Health Net Access as part of the claims adjudication process unless Health Net Access returned the information to the provider.
Health Net Access does not discriminate or retaliate against a provider due to a provider's use of the provider dispute process.
Acknowledgment of Provider Disputes
Health Net Access acknowledges receipt of each provider dispute, regardless of whether or not the dispute is complete, within 5 business days of receipt.
Health Net Access resolves each provider dispute within 30 calendar days following receipt of the dispute, and provides a written determination.
Past Due Payments
If the provider dispute involves a claim and it is determined to be in favor of the provider, Health Net Access pays any outstanding money due, including any required interest or penalties, within fifteen business days of the date of the decision. When applicable, accrual of the interest and penalties will commence on the day following the date by which the claim should have been processed.
Dispute Resolution Costs
A provider dispute is processed without charge to the provider; however, Health Net Access has no obligation to reimburse any costs that the provider has incurred during their dispute process.
Provider State Fair Hearing
If a provider disagrees with the resolution of a dispute, he or she may file a request to Health Net Access for a State Fair Hearing through the AHCCCS Office of Administrative Legal Services (OALS). The request must be received in writing within 30 days of the dispute decision and the Health Plan will submit all supporting documentation received to the OALS, no later than five business days from the date the Health Net Access receives the provider's written request.
When a provider files a written request for a hearing, Health Net Access will review the matter to determine why the request for hearing was filed and resolve the matter when appropriate. If Health Net Access decides to reverse, in full or in part, through the appeal process, Health Net Access will reprocess and pay the claim(s) in a manner consistent with the decision along with any applicable interest within 15 business days of the date of the decision.
All provider disputes and supporting information must be submitted to:
|Line of Business||Address|
|Health Net Access Provider Disputes||Health Net Access Appeals Unit
1230 W. Washington Street, Suite 401
Tempe, AZ 85281-1245