Claims

The CHOC Health Alliance Claims Customer Service Department is here to help you with any claim inquiries, including questions about initial claims, resubmissions, and denials. We can be reached at 1 (800) 387-1103

CHOC Health Alliance Provider

Providers must submit claims and encounters to CHOC Health Alliance for ALL services.

Medi-Cal Guidelines

Electronic and paper claims must follow Medi-Cal billing guidelines. For more information, visit www.medi-cal.ca.gov.

Timely Filing

File a claim on an electronic or paper form within 90 calendar days of the date of service, unless otherwise specified by your contract. Failure to follow these guidelines may result in denial and nonpayment. (Non-contracted providers are subject to Medi-Cal billing guidelines.)

Electronic Claim Submission

Submitting claims electronically is safe, faster, and easier to track than paper claims. If you are not already using an electronic billing system, you may contact a clearinghouse directly, at the following:

Submitting paper claims

If you cannot submit claims electronically, please mail paper claims to the address below. Remember to include supporting medical documentation when necessary.

Processing Time

The standard processing time for a claim is 30 business days from the date CHOC Health Alliance receives the claim.

Status Updates

To check claim status:

Online: EZ-Net (link to form)

Phone: Claims Department at (800) 387-1103, Option 1

Corrected Claims

A resubmission of an existing claim. The corrected claim tells CHOC Health Alliance that you are rebilling a previously submitted claim with the correct codes and/or modifiers, with the goal of payment.

Corrected Claim Submission

Make the changes to the CPT, ICD-10, modifiers, etc. on a new paper form

Stamp “corrected claim” in box 22 of the CMS-1500 form

Send the corrected claim to:

Coordination of Benefits (COB)

Is required when a member is covered by one or more health insurers in addition to CHA. CHA is the payer of last resort and should be billed after all others.

Billing CHOC Health Alliance and other Health Coverage

File claim, with the primary insurer.

If the primary insurer issues a partial payment or denial, submit a claim with a copy of the Explanation of Benefits (EOB), including payment details, to CHA.

If appropriate, CHA will pay the remaining balance up to the Medi-Cal allowable amount.

Provider Dispute Process

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. To download the guideline for Claims Settlement Practices & Dispute Resolution Mechanism select, 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

Download the Provider Dispute Resolution Request form: PDR Form

Fill out the form and attach supporting documentation.

Mail the completed form and documents 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.