Non-Contracted Provider Payment Appeal Process

Under the Knox-Keene Act of the State of California, the patient to whom services were provided is not liable for any portion of the bill, except for copays or non-benefit items, if applicable. The provider should not bill the patient or accept collection against the patient. The applicable regulation is 1379 of the Knox-Keene Act.

AB72/Cal. H&S Code State of California prohibits surprise billing for services rendered to Commercial members by non-contracted providers in a contracted facility.

Providers have a right to file a formal dispute regarding a claim or contract. For instructions on submitting a formal dispute, call Customer Service listed on your Remittance Advice. Mail disputes to: Provider Disputes, PO Box 211624, Eagan MN 55121. For electronic instructions and submission, visit Sutter Link. Check your claim's status online.

Explanation of Payment (PDF)

Effective January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) expanded its current provider payment appeal process for appeals between non-contracted and deemed providers and Private Fee for Service Plans (PFFS) to include disputes between non-contracted providers and all of the following:

• Medicare Advantage Organizations (HMO, PPO, RPPO and PFFS)
• 1876 Cost Plans
• Medi-Medi Plans
• Program of All-Inclusive Care for the Elderly (PACE) organizations

Appeals Process for Non-Contracted Medicare Providers:
Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination, in whole or in part, including issues related to bundling, level of care, or down coding of services/DRG. To appeal a claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum:

• A statement indicating factual or legal basis for appeal
• A signed Waiver of Liability form (you may obtain a copy by going to: 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

Alignment Health Plan:
Alignment Health Plan
Attn: Appeals Department
PO Box 14010
Orange, CA 92863

Health Net Seniority Plus:
Health Net Medicare Programs Provider Services Department
PO Box 10406
Van Nuys, CA 91410-0406

Humana:
Humana
Attn: Grievance and Appeal Department
PO Box 14165
Lexington, KY 40512-4165
(800) 949-2961 (Fax)

Stanford Health Care Advantage Claims
Attn: Non-Contracted Provider Appeals
P.O. Box 71210
Oakland, CA  94612-7310

Blue Shield of California
Attn: Provider Appeals
P.O. Box 272640
Chico, CA 95927-2640

UnitedHealthCare
P.O. Box 6106 MS CA 124-0157
Cypress, CA 90630

Medicare Non-Contracted Provider Appeals Process for Care 1st Only:
Provider Appeals must be submitted to SEBMF within 60 calendar days after the receipt of notice of initial determination/decision. Providers who wish to submit provider appeals to SEBMF must also submit a signed a Waiver of Liability statement holding the member harmless regardless of the outcome of the appeal. Refer to Medicare Managed Care Manual, Chapter 13, Section 60.1.1.

Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers 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 have 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

Please refer to the Remittance Advice for payment dispute address.

If you do not agree with the dispute determination, you have the option to request a Health Plan dispute review. Please send all dispute requests in writing, accompanied by all documentation to support your position, directly to the Provider Appeals and Disputes team by using the following address:

Care 1st Health Plan
Attn: Provider Dispute Dept
PO Box 3829
Montebello, CA 90640

Stanford Healthcare Advantage
Attn: Dispute Department
PO Box 5904
Troy, MI 48007

Alignment Health Plan
Attn: Non-contracted Provider 2nd Level PDR
P. O. Box 14010
Orange, CA 92863-9936

Medicare Non-Contracted Provider Dispute Process for Care 1st Only:
Provider Disputes must be submitted to SEBMF, at the address listed below, within 120 calendar days after the notice of initial payment determination.

Items that may be filed as Provider Disputes include:

• Underpayment (payment less than the Medicare fee schedule); or
• Disagreement about our decision to make payment on submitted procedure code or downcoding

You may submit your second level written request to Care1st 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’ve 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.