Provider Dispute Resolution
MHN has established a provider dispute resolution process for both individual practitioners and facility providers, that provides consistent, timely, and effective de novo review of an issue that has not been satisfactorily resolved through our regular provider customer service channels. This process is available to both contracted and non-contracted providers.
The first steps towards resolving a dispute are outlined below.
NOTE: The majority of issues with authorizations, claims can be resolved through Customer Service or the Service Team.
- If you have a concern involving a claims payment issue, please call our Customer Service Department at (800) 444-4281.
- If you have a concern regarding authorizations and/or wish to access care for a member, please call the MHN Service Team to obtain the member's employer group. This number is referenced in your authorization letter and/or should be listed on the back of the member's medical insurance ID card.
- If you have a concern that involves a contracting status, please call our Professional Relations Representatives at (800) 541-3353, 10:00 AM to 2:00 PM Pacific Time Zone.
- For cases where authorization has been denied because the case does not meet medical necessity criteria, please follow the dispute resolution process below.
- If you suspect fraud or abuse in the provision of services or submission of claims, please contact our Fraud & Abuse Hotline at (800) 327-0566.
If the steps outlined above do not fully resolve your concern, please use the Provider Dispute Resolution Request Form (PDF). [New Jersey providers please see special state-specific section below.]
Definition of Contracted Provider Dispute.
A contracted provider dispute is a provider's written notice to MHN challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered) or disputing a request for reimbursement of an overpayment of a claim.
Each contracted provider dispute must contain, at a minimum, the following information: provider's name, billing provider's tax ID number or MHN's provider ID number, provider's contact information,and:
- If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from MHN to a contracted provider the following must be provided: original claim form number (located on the RA), a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect;
- If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider's position on such issue; and
- If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s)of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service and provider's position on the dispute, and an enrollee's written authorization for provider to represent said enrollees.
Sending a Contracted Provider Dispute to MHN.
Contracted provider disputes submitted to MHN must include the information listed above, for each contracted provider dispute. To facilitate resolution, providers should use the Provider Dispute Resolution Request form to submit the required information. All contracted provider disputes must be sent to the attention of Provider Disputes at the following:
P.O. Box 10697
San Rafael, CA 94912
Time Period for Submission of Provider Disputes.
Contracted provider disputes must be received by MHN within 365 calendar days from MHN's action that led to the dispute or the most recent action if there are multiple actions that led to the dispute, or in the case of inaction, contracted provider disputes must be received by MHN within 365 calendar days after MHN's time for contesting or denying a claim (or most recent claim if there are multiple claims) has expired.
Contracted provider disputes that do not include all required information as set forth above may be returned to the submitter for completion. An amended contracted provider dispute which includes the missing information may be submitted to MHN within thirty (30) working days of your receipt of a returned contracted provider dispute.
Acknowledgment of Contracted Provider Disputes.
MHN will acknowledge receipt of all contracted provider disputes within fifteen (15) working days of the Date of Receipt by MHN.
Contact MHN Regarding Contracted Provider Disputes.
All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute or other inquiries must be directed to Claims Customer Service at MHN at (800) 444-4281.
Instructions for Filing Substantially Similar Contracted Provider Disputes.
Substantially similar multiple claims, billing or contractual dispute,should be filed in batches as a single dispute, and should be submitted using the Provider Dispute Resolution Request - Multiple Like Claims form.
Time Period for Resolution and Written Determination of Contracted Provider Dispute.
MHN will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) working days after the Date of Receipt of the contracted provider dispute or the amended contracted provider dispute.
Past Due Payments.
If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, MHN will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) working days of the issuance of the written determination.
Do not bill members for days denied by MHN. Your contract does not permit it. Instead, please submit the Provider Dispute Resolution Request form with the required information to the address listed above.
Definition of Non-Contracted Provider Dispute.
A non-contracted provider dispute is a non-contracted provider's written notice to MHN challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim. Each non-contracted provider dispute must contain, at a minimum, the following information: provider's name, billing provider's tax ID, contact information, and:
- If the non-contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from MHN to provider the following must be provided: original claim form number (located on the RA), a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect; and
- If the non-contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service, provider's position on the dispute, and an enrollee's written authorization for provider to represent said enrollees.
Dispute Resolution Process.
The dispute resolution process for non-contracted providers is the same as the process for contracted providers as set forth above.
Notice of Overpayment of a Claim.
If MHN determines that it has overpaid a claim,MHN will notify the provider in writing through a separate notice clearly identifying the claim, the name of the patient, the Date of Service(s) and a clear explanation of the basis upon which MHN believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.
If the provider contests MHN's notice of overpayment of a claim, the provider, within 30 Working Days of the receipt of the notice of overpayment of a claim, must send written notice to MHN stating the basis upon which the provider believes that the claim was not overpaid. MHN will process the contested notice in accordance with MHN's contracted provider dispute resolution process described above.
If the provider does not contest MHN's notice of overpayment of a claim, the provider must reimburse MHN within thirty (30) working days of the provider's receipt of the notice of overpayment of a claim.
External Review Statistics - MHN will post in this section, for each geographic area or licensed plan, the number of Medical Necessity disputes sent to an External Review Organization for final determination for each preceding calendar year and the percentage of such appeals that are upheld or overturned, beginning with December 1, 2005 and every calendar year thereafter.
Appeals Sent for External Review:
The number and outcome of any External Reviews will be reported on an annual basis
|Number of Appeals||Number of Appeals Reversed (%)||Number of Appeals Upheld (%)|
1. New Jersey - The Provider can obtain a signed permission to appeal from the member at the time of admission to treatment. This permission to represent the member for any medical necessity appeals shall remain in force through all levels of appeal unless specifically revoked by member. Per the New Jersey Claims Act of 2006, the provider shall notify the member each time he initiates an appeal or any additional stage of appeal. The Provider must obtain the member's consent prior to filing an external appeal. Such clinical appeals from the provider will follow the same processes as all New Jersey member appeals (Level 1 being resolved in 5 business days and Level 2 in 20 business days) for accounts that MHN underwrites in New Jersey. All administrative provider disputes will be investigated and resolved within 30 calendar days by staff members not involved in the day-to-day claims payment process. If the Provider has submitted the dispute on a New Jersey Application to Appeal a Claims Determination (228K PDF), the form specifically designated for provider dispute purposes by the New Jersey Department of Banking and Insurance (DOBI), then the provider may be eligible to pursue external arbitration through the New Jersey DOBI within 90 calendar days of a decision by MHN upholding its original claim determination. Detailed instructions as well as an arbitration application form are included with every administrative provider dispute upheld by MHN. The information and the form can also be found on the New Jersey DOBI’s website at www.state.nj.us/dobi.
2. New York - New York providers treating MHN members with accounts underwritten in New York have the right to apply for state external review of any medical necessity disputes that MHN upholds. An application form and instructions are included with any MHN determination to uphold its original decision.
3. California - Effective 2014 Health Net of California's MediCal plans now include behavioral health benefits. Health Net / MHN is only administering minimal to moderate behavioral health outpatient treatment services (Individual/Group Therapy, Medication Management, Psychological Testing, Lab, etc) portion of the agreement. Specialty Mental Health Services and higher level of care treatment services is handled by the respective County Mental Health Department. MHN is delegated to facilitate Provider Dispute Requests (PDR) through final determination. Because each county administers the MediCal benefits, some may have special rules, program names, and notification requirements (letters). MediCal PDR review procedures are otherwise the same as any other PDR case.