Disputed Charge Process

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Dispute Process for Charges From your Provider

Please review the following scenarios to determine how to dispute the
Point of Service charges.

Emergency care If you believe your care was due to an emergency, you may file a claim appeal. Please review the NOVA Pathfinder HealthCare definition of emergency care to determine if an appeal is appropriate. You contacted your Primary Care Doctor (PCD) after the service, you did not know a referral was needed, the service was a follow up to preventive care, or you did not realize the referral had expired As a NOVA Pathfinder HealthCare member, it is your responsibility to be aware of the referral requirements. Point of Service charges cannot be waived if you did not follow the referral requirements. Your PCD/hospital or clinic cannot submit a retroactive referral for these circumstances. Your PCD/hospital or clinic appointment line/referral manager failed to submit the referral to Nova Pathfinder Limited HealthCare or gave you misinformation NOVA Pathfinder advises its members to contact the hospital’s or clinic’s patient advocate to determine if he/she will submit a referral for services already rendered. If the referral is approved, members can then contact NOVA for a claim adjustment. NOVA does not have review rights for this circumstance, and the local hospital or clinic determination is final. Your PCD failed to submit the referral to NOVA or the referral was submitted and rejected If your PCD gave you a written referral but did not submit a referral to NOVA, you may submit a copy of the written referral. If the referral was verbal, you may submit a written statement from the provider indicating when the verbal referral was given. Submit the documentation with a copy of the Explanation of Benefits to:

Nova Pathfinder Limited Healthcare Claims Correspondence

5739 Kanan Road Suite #336, Agoura, CA 91301

Misinformation from a NOVA Pathfinder Limited HealthCare customer service representative If our customer service records indicate misinformation or incomplete information was provided, the Point of Service charges may be adjusted. You may submit a request for review online or via U.S. mail.

Email via secure Encryption I to appeals@mynovahealthcare.org

U.S. mail: Nova Pathfinder Limited Healthcare Claims Correspondence

5739 Kanan Road Suite #336, Agoura, CA 91301

Other reasons not listed above You may submit a request for review online or via U.S. mail.

Email via secure Encryption I to appeals@mynovahealthcare.org

U.S. mail:

Nova Pathfinder Limited Healthcare Claims Correspondence

5739 Kanan Road Suite #336, Agoura, CA 91301

Filing a Grievance

A grievance is a written complaint or concern about a medical provider, TAMS or the Nova Pathfinder Limited Healthcare program in general. Authorization appeals,  claims appeals, and claim review issues are separate from grievances. The following are examples of grievances:

  • Quality of services provided by a provider (inadequate service, ineffective care, inaccurate results) 
  •  Providers’ conduct or actions and their personnel Inaccurate information
  • Delays or mistakes in the processing of authorizations
  • Patient protection issues at a hospital or doctor’s office
  • Privacy issues

Note: Disputing charges for services should not be submitted as a grievance.

Who can file a Grievance?

Anyone can file a grievance; however, if the grievance is about someone other than the person who filed the grievance, NOVA Pathfinder may not be able to give a full response without an Authorization for Disclosure of Medical or Dental Information form on file; this generally applies to spouses and parents of adult children submitting grievances about their spouse or adult child.

What is the Grievance Process?

NOVA Pathfinder HealthCare takes complaints seriously. We will conduct a thorough investigation of the concerns and take actions as necessary to improve services. If necessary, we will contact the involved provider(s) and various NOVA Pathfinder departments to gather additional information. Generally, we do not contact the member unless information in the grievance is unclear. The person who submitted the grievance will receive a written response, usually within 60 days.

How is a grievance submitted?

Print an  Nova Pathfinder Limited HealthcareGrievance Form or
send a letter with the following:

  • Name, address and telephone number of the person submitting the grievance
  • The member’s name, address and telephone number if different from the submitter
  • The member’s Social Security number or the beneficiary’s Social Security number
  • A description of the issue(s), including the day, time and details
  • The name of the involved provider(s) or NOVA associates
  • The provider’s address if the complaint is about a provider
  • Any appropriate supporting documents
  • If necessary, an Authorization for Disclosure of Medical or Dental Information form

Fax to: 1-805-375-6090

Mail to: NOVA Pathfinder HealthCare Limited Healthcare Grievances 5739 Kanan Road, Suite 335 Agoura, CA 91301