Claims Dispute Resolution Mechanism:
This information notice is intended to inform you of your rights, responsibilities, and related procedures to the claim settlement practices and claim disputes process for CalOptima Medi-Cal, members where CHOC Health Alliance is delegated to perform claims payment and provider dispute resolutions. By selecting this document, CHOC Health Alliance Downstream Provider Notice, you will have full access to the process for resolving claims disputes.
A provider dispute is a provider’s written notice to CHOC Health Alliance challenging, or appealing a payment of a claim, denial of a claim, adjusted or contested, seeking resolution of a billing determination or other contract dispute or disputing a request for reimbursement of an overpayment to a claim.
We are dedicated to performing claims payment and provider dispute resolution process as set forth in Sections 1300.71 and 1300.71.38 of Title 28 of the California Code of Regulations.
Before you begin a claim dispute, exhaust all avenues by contacting the Claims Inquiry Claims Research (CICR) Department by phone at 800-387-1103 for additional information regarding the claim that is in question to facilitate a reconsideration.
A reconsideration is defined as a request for review of a claim that you believe was incorrectly paid or denied because of a processing error.
A claim that is stamped as either a ‘resubmission’ or ‘reconsideration’ is not considered a dispute or an appeal. Claims received in our provider dispute and appeals department as a ‘claim correction’ will be acknowledged and returned to the provider with instructions to mail to the appropriate claims address. See your Provider Manual for more information.
How to file a dispute
A claim dispute must be labeled as such and must include all supporting documentation.
You must mail your dispute to:
CHOC/CPN Claims – c/o Rady Children’s Hospital San Diego
3020 Children’s Way., MC5144
San Diego, Ca. 92123
Time period for submission of provider disputes
- Provider disputes must be received by CHOC Health Alliance within 365 calendar days from CHOC Health Alliance’s action that led to the dispute (or the most recent action if there are multiple actions) that led to the dispute.
- Provider disputes that do not include all required information may be returned to the submitter for completion. An amended provider dispute that includes the missing information may be submitted to CHOC Health Alliance within 30 working days of the receipt of a returned provider dispute.
Acknowledgment letter
CHOC Health Alliance will acknowledge receipt of all provider disputes as follows:
- By mail: Within 15 working days with postage-paid envelope.
If you do not receive an acknowledgment letter, call the Dispute Department at 800-387-1103.
Processing time
CHA will issue a written statement with the pertinent facts and explaining the reasons for the dispute determination within 45 days.
Decision letter
If the decision is in favor of the provider, payment is made with applicable interest within 5 working days of the decision or if interest is less than $2, it can be paid within 10 days of the close of the calendar month in which the original claim was paid.
Second-level disputes
Providers who are not satisfied with the decision after completing the dispute process may seek relief by filing a second-level appeal with the Grievance and Appeals Resolution Services (GARS) staff at CalOptima.
