Revised Provider Dispute Process

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The Alliance offers the Provider Dispute Resolution Process for providers to resolve claim processing issues. In the past, providers completed a Provider Dispute Form to dispute a claim. Effective Jan. 2, 2019, the Alliance has implemented a two-level process to resolve provider inquiries and disputes regarding claim payment issues. A first-level provider inquiry process is now required for all contested claim requests, and providers must complete the provider inquiry process prior to submitting a second-level dispute.

The Alliance scans and reviews all inquiries, disputes and written statements of contested claims or provider dissatisfaction to determine if the request meets criteria for processing as a provider inquiry (level 1) or a dispute (level 2). The Alliance will process written statements and requests according to the criteria stated in the definitions for these processes. Please refer to the Provider Inquiry Form (link below) for definitions, details, and further information.

The Alliance has created a new Provider Inquiry Form (PIF) that providers may use to submit inquiries, disputes, and corrected claims. This new form is located on the Form Library page of the Alliance provider website. Provider inquiries, disputes, and corrected claims should be sent to:

Central California Alliance for Health
ATTN: Provider Inquiries and Disputes
1600 Green Hills Rd, Suite 101
Scotts Valley, CA 95066

Provider inquiries and disputes may also be faxed or emailed to:

Fax: (831) 430-5569
E-mail: [email protected]

Inquiries and disputes must be filed with the Alliance within 365 days of the date of the Explanation of Benefits (EOB). For questions about provider inquires and disputes, please contact a Claims Customer Service Representative at (831) 430-5503, Monday through Friday, 9 a.m. – 4 p.m.