Provider Disputes and Appeals
1st Level Provider Disputes
ATTN: Provider Disputes
P.O. Box 7280
Los Angeles, CA 90022-0980
Provider-Dispute-Request-Form.doc
Medi-Cal: Disputes must be submitted in writing preferably with the approved “Provider Dispute Resolution Request” (PDR) form, within 365 calendar days of payment/denial. Disputes must state the reason of the dispute, the expected outcome, and may
include a copy of the claim form and any supporting documentation. You will be notified in writing within 45 working days of the outcome of the dispute.
Commercial: Disputes must be submitted in writing preferably with the approved “Provider Dispute Resolution Request” (PDR) form, within 365 calendar days of payment/denial. Disputes must state the reason of the dispute, the expected outcome, and may
include a copy of the claim form and any supporting documentation. You will be notified in writing within 45 working days of the outcome of the dispute.
Pursuant to California Code of Regulations Title 28, Sections 1300.71 and 1300.71.38, a provider may file a written dispute to: ATTN Provider Disputes P.O. Box 7280 Los Angeles CA 90022 to challenge, appeal, or request for a reconsideration on a claim(s) that has been denied, adjusted, or contested.
Provider Disputes must be filed to within 365 days from the last date of written notification that led to the dispute. For instructions and forms for submitting a dispute, please see the provider dispute request form linked above.
The dispute request must include the following information:
- Name address and phone number of the provider of service
- Provider’s tax id number
- Patient name
- Insurer’s information
- Date of service
- A complete and accurate explanation of the issue supporting documentation including copies of claims, claim number, medical records, or supporting documentation to challenge reports, as necessary, from the initial adverse determination.
Non-Emergency Services
Independent Dispute Resolution Process (AB 72 IDRP)
The law requires that the Department of Managed Health Care conduct an independent dispute resolution process (AB 72 IDRP) that allows a non-contracting provider who rendered services at, or as a result of services at, a contracting health facility, or a payor, to dispute whether payment of the specified rate was appropriate. Once a non-contracting provider or payor submits an AB 72 IDRP Application, the opposing party is required by law to participate in the AB 72 IDRP. AB 72 does not apply to emergency services and care.
Eligible Claims
Eligible claim disputes are those disputes that are subject to DMHC jurisdiction and meet all of the following criteria:
- The disputed claim must be for services rendered on or after July 1, 2017.
- The disputed claim must be for non-emergency services. If there is an unresolved dispute as to whether the health care service(s) at issue is non-emergent, the claim does not qualify for the AB 72 IDRP.
- The disputed claim must be for covered services provided at a contracting health facility, or provided as a result of covered services at a contracting health facility, by a non-contracting individual health professional.
- The non-contracting provider has completed the health plan or payor’s Provider Dispute Resolution (PDR) process within the last 365 days.
- The non-contracting provider is not a dentist.
- The payor is not a Medi-Cal managed health care service plan or any other entity that enters into a contract with the State Department of Health Care Services
For more information or to submit a dispute under the IDRP process, please go the California Department of Managed Health Care’s website at:
Covered CA: Disputes must be submitted in writing preferably with the approved “Provider Dispute Resolution Request” (PDR) form, within 365 calendar days of payment/denial. Disputes must state the reason of the dispute, the expected outcome, and may
include a copy of the claim form and any supporting documentation. You will be notified in writing within 45 working days of the outcome of the dispute.
Medicare Contracted Providers: You may submit your request for reconsideration of the initial payment/denial within 365 calendar days of the payment/denial.
Provider Dispute: Pursuant to federal regulations governing the Medicare Advantage program, non-contracted health care professionals may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider contends the amount paid by the Plan for a Medicare covered service is less than the amount that would been paid under Original Medicare. To dispute a claim payment, submit a written request within 120 calendar days of the remittance notification date and include at a minimum:
- A statement indicating factual or legal basis for the dispute
- A copy of the original claim
- A copy of the remittance notice showing the claim payment
- Any additional information, clinical records or documentation to support the dispute
Appeal Process: Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination including issues related to budling or downcoding of services. To appeal a claim denial, submit a written request within 65 calendar days of the remittance notification date and include at minimum:
- A statement indicating factual or legal basis for appeal
- A signed Waiver of Liability form (you may obtain a copy on): https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/model-waiver-of-liability_feb2019v508.zip
- A copy of the original claim
- A copy of the remittance notice showing the claim denial
- Any additional information, clinical records or documentation
Billing Alerts: Section 1905(n) of the Social Security Act prohibits a provider from billing an individual with coverage as a Qualified Medicare Beneficiary (QMB), with or without other Medicaid coverage, or someone receiving Supplemental Security Income benefits and Medicare for the Medicare deductible or coinsurance.
Mail the Appeal request to:
| Aetna Medicare Health Plan P.O. Box 14067 Lexington, KY 40512 Fax: 1-866-604-7092 |
Blue Shield of California Provider Dispute Office - Commercial P.O. Box 272620 Chico, CA 95927-2620 |
Clever Care Health Plan Appeals and Grievances Department 7711 Center Ave, Suite 100 Huntington Beach, CA 92647 |
Senior Buena Care P.O. Box 7280 Los Angeles, CA 90022-0980 |
| Alignment Healthcare Attn: Provider Appeals and Disputes P.O. Box 14012 Orange, CA 92863 |
Brand New Day Provider Appeals Department P.O. Box 93122 Long Beach, CA 90809 |
IEHP Provider Claims Resolution Recovery Unit P.O. Box 4319 Rancho Cucamonga, CA 91729-4319 |
United Healthcare Mail Stop CA 124-0157 P.O. Box 6106 Cypress, CA 90630 |
| Anthem Blue Cross Appeals & Grievance Unit 4361 Irwin Simpson Road Mail Stop OH 205-A537 Mason, OH 45040 |
CalOptima Grievance and Appeals Dept 505 City Parkway West Orange, CA 92868 |
Imperial Health Plan of California P.O. Box 60874 Pasadena, CA 91116 |
WellCare by Health Net Provider Appeal Claims P.O. Box 3060 Farmington, MO 63640-3822 |
| Astiva Health 765 The City Drive South, Ste. 200 Orange, CA 92868 |
Central Health Appeals & Grievances P.O. Box 14246 Orange, CA 92863 |
L.A. Care Health Plan Appeal & PDR Unit P.O. Box 811610 Los Angeles, CA 90081 |
WellCare Health Plan Appeals P.O. Box 31368 Tampa, FL 33631 |
| Blue Shield of California Promise Health Plan - Medi-Cal First Source - BSCPHP P.O. Box 8309 Chico, CA 95927-8309 |
Champion Health Plan P.O. Box 15337 Long Beach, CA 90815-9995 |
Molina Medicare Appeals ATTN: Provider Appeals P.O. Box 22817 Long Beach, CA 90801 |
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| Blue Shield of California Provider Dispute Resolution - Medicare P.O. Box 272640 Chico, CA 95927-2640 |
Cigna HealthCare of California, Inc. C/O Altura MSO P.O. Box 7280 Los Angeles, CA 90022-0980 |
SCAN Non-Contracted Appeal P.O. Box 22616 Long Beach, CA 90801 Fax: 562-989-0958 |
Notices and Forms
Medicare health plans must meet the notification requirement for grievances, organization determinations, and appeals processing under the Medicare Advantage regulations found at 42 CFR 422, Subpart M. Details on the applicable notices and forms are available below (including English and Spanish versions of the standardized notices and forms).
2nd Level Provider Disputes
If you still are not satisfied with the outcome of your 1st Level Dispute, you may submit a 2nd Level Dispute directly to the Health Plan or IPA. Please make sure to include a copy of the final determination from your 1st Level Dispute. Please make sure to label the dispute as a “2nd Level Dispute”.
You may submit your second level written request to the health plan if you disagree with our decision on your first level dispute by mail within 180 calendar days of written notice from us or within 30 calendar days from the time, we have received your request if you have not heard from us.
Denials due to coverage determination and medical necessity determinations are not subject to provider dispute process. These items must be submitted as provider appeals.
If you do not agree with the dispute determination, you have the option to request a Health Plan or IPA dispute review. Please send all dispute requests in writing, accompanied by all documentation to support your position, directly to the Health Plan or IPA by using the address listed below:
For United Healthcare Medicare members, Non-Contracted Providers may submit their 2nd Level Dispute directly to Altura MSO. The 2nd Level Provider Dispute must be received by Altura MSO within 120 calendar days from the determination date of the initial dispute.
For Commercial PDR – if dispute is related to AB72 payment, you may file an IDRP through DMHC.
For Commercial/Medi-Cal PDRs – if dispute is related to medical necessity or UM, you have a right to appeal the decision directly to the health plan within 60 working days from the initial determination.
| Aetna Provider Resolution Team P.O. Box 14079 Lexington, KY 40512 |
Brand New Day Provider Appeals Department P.O. Box 93122 Long Beach, CA 90809 |
Health Net of California, Inc. Medicare Claims P.O. Box 9030 Farmington, MO 63640 |
Newport Health Plan 4790 Irvine Blvd. Suite 105-328 Irvine, CA 92620 |
| Alignment Healthcare Attn: Provider Appeals and Disputes PO Box 14012 Orange, CA 92863 |
CalOptima ATTN: Claims Resolution Unit P.O. Box 57015 Irvine, CA 92619 |
Health Net of California, Inc. (and/or Health Net Life Insurance Company) Commercial Claims P.O. Box 9040 Farmington, MO 63640 |
SCAN Health Plan 2nd Level Non-contracted Provider Dispute P.O. Box 21543 Eagan MN 55121 Fax: 562-997-1835 |
| Anthem Blue Cross Appeals & Grievance Unit 4361 Irwin Simpson Road Mail Stop OH 205-A537 Mason, OH 45040 |
Central Health Contracting & Network Development Department / Dispute Division P.O. Box 14246 Orange, CA 92863 |
IEHP Provider Claims Resolution Recovery and Unit P.O. Box 4319 Rancho Cucamonga, CA 91729-4319 |
Senior Buena Care P.O. Box 7280 Los Angeles, CA 90022-0980 |
| Blue Shield Dispute Resolution Office P.O. Box 272620 Chico, CA 95927 |
Cigna HealthCare of California, Inc. C/O Altura MSO P.O. Box 7280 Los Angeles, CA 90022-0980 |
L.A. Care Health Plan Appeals & PDR Unit P.O. Box 811610 Los Angeles, CA 90081 |
United Healthcare C/O Altura MSO P.O. Box 7280 Los Angeles, CA 90022-0980 |
| Blue Shield Promise Appeals & Grievance Unit P.O. Box 3829 Montebello, CA 90640 |
Health Net Community Solutions, Inc. Medi-Cal Claims P.O. Box 9020 Farmington, MO 63640 |
Molina HealthCare Provider Dispute Resolution P.O. Box 22722 Long Beach, CA 90801 |
WellCare ATTN: Appeals Department P.O. Box 31368 Tampa, FL 33631-3368 |