TRICARE West - Health Net Appeals Form
Here is a preview of what will be submitted to Health Net. You will be able to print the form and obtain a tracking number after submission.
Submitter Information
Relationship to Patient / Beneficiary
Relationship Description:
Group/Facility Name:
Individual Provider Name:
Tax ID Number (TIN):
Agency Name:
First Name:
Date of Birth:
Street Address:
City:
State:
Zip Code:
Daytime Phone Number:
Extension:
Daytime Fax number:
Email Address
Sponsor Information
Name:
SSN:
PATIENT / BENEFICIARY INFORMATION
Name:
Date of Birth:
Street Address:
City:
State:
Zip code:
RENDERING PROVIDER / FACILITY INFORMATION
Group/Facility Name:
Individual Provider Name:
Street Address:
City:
State:
Zip code:
Daytime Phone:
Extension:
Fax Number:
Tax ID Number (TIN):
CLAIM OR AUTHORIZATION DENIAL INFORMATION
Have the Services Occurred?
Claim Number(s):
Date of Service From:
Date of Service To:
Authorization/Reference Number(s):
CPT, HCPC or description of Service or Procedure Denied:
Date of Denied Claim or Authorization:
Issue in Dispute
Please state the specific reason for your appeal. Try to be brief, but be sure to include the rationale for your request or the reason you believe the service should be covered.
You may send additional supporting documentation to Health Net Federal Services Appeals Department via fax at 1-844-769-8007 or by mail to:
Health Net Federal Services
Appeals Auth
P.O. Box 2219
Virginia Beach, VA 23450-2219
Please check this box if you intend to submit additional documentation via fax or mail.
Additional Documents:
Note: Since you checked the additional documents box, we will suspend processing the appeal up to ten (10) calendar days. If the additional documents are not received in the next ten (10) days we will then continue to process your appeal. If you need more than ten (10) days to gather additional information you may reschedule your appeal by submitting written notification. To re-open the appeal, a written request must be received within 20 calendar days of submitting this appeal or by the appeal-filing deadline set forth in the initial denial notice, whichever is later. The request to reschedule the appeal or to re-open the appeal may be submitted via this online form.