California PHP

A provider dispute is a provider’s written notice challenging, appealing or requesting reconsideration of a claim (or a bundled group of similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract disputes or disputing a request for reimbursement of an overpayment of a claim.

Each provider claim dispute must contain the following information at a minimum:

• Provider’s name
• Provider’s identification number
• Provider’s contact information
• If the provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from PHP to a provider, the request must include:
  • A clear identification of the disputed item
  • The date of service
  • A clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect.

Providers may submit disputes on a Provider Claims Dispute Submission Form.

Providers may initiate a claims dispute no later than 365 days from the date of the plan’s action on a claim.

PHP sends written acknowledge of receipt of a provider claim dispute submission within 15 business days for hard copy submission, and two (2) business days for electronic submission. The plan will return provider claim disputes to submitting providers who do not include the required information as described above. Providers have 30 calendar days from receipt of a returned provider claim dispute to submit an amended dispute. If a provider does not submit an amended provider claim dispute within the 30-day time frame, the plan closes the dispute.

PHP issues a written determination regarding a provider claim dispute within 60 calendar days after receipt of the dispute. For those provider claim disputes that require amending by the provider, the plan issues a written determination within 60 calendar days after receipt of an amended dispute.

Provider claim disputes and appeals should be faxed or mailed.

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