Provider Resources
Care Coordination
Claims & Eligibility
Pharmacy Services
Training and Compliance
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Care Coordination
Prior Authorization For Medical Services
Contracting and non-contracting providers can contact Utilization Management at 1-877-208-4959 to request to obtain prompt authorization.
View CCHP’s policy on Prior Authorization on Medical Services.
Special Needs Plans Training
Timely Access to Care
Complex Case Management
Our Complex Case Management Program is designed for members with multiple chronic conditions, particularly those with uncontrolled Type II diabetes (HbA1c ≥ 8.0%) and heart failure. Enrollment in this program will not affect your benefits. Members and providers are encouraged to complete this referral form for program consideration. Click here to be directed to our Complex Case Management page.
Claims and Eligibility
Filing Claims
Electronic Claims Submission
CCHP prefers claims to be submitted electronically. For information, please contact our Member Services.
Paper Claims Submission
All paper claims must be submitted using a CMS 1500 form (for professional providers) and a UB-92 form (for institutional providers). Please send your paper claims to: CCHP Claims Department, Post Office Box 1599, San Leandro, CA 94577.
*Upon reviewing claims in the Provider Portal, if you still have questions or require additional information regarding denial reasons, payment amounts, or EOP requests, please reach out to us at providerinquiry@cchphealthplan.com.
*Inquiries will be acknowledged within 5 business days, triaged, and sent to the appropriate CCHP team for review. Status updates will be provided for managed inquiries.
Provider Dispute Process
CCHP has a Provider Dispute Resolution (PDR) process that ensures provider disputes are handled in a fast, fair, and cost-effective manner.
A provider dispute is a written notice from a provider that:
- Challenges, appeals, or requests for reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted, or contested
- Challenges a request for reimbursement for an overpayment of a claim.
- Seeks resolution of a billing determination or other contractual dispute.
How to Submit Provider Disputes
Providers must use a Provider Dispute Resolution and Appeal Request Form
You may download Instructions for Submitting Provider Disputes or call CCHP Provider Dispute Relations at Phone: 1-415-955-8800 (Press 2 for Providers) for assistance.
Disputes can be mailed to CCHP Provider Dispute Resolution Area, 445 Grant Avenue, San Francisco, CA 94108, or faxed to 1-415-955-8815.
Resolution Timeframe
CCHP will resolve each provider dispute within 45 business days following receipt of the dispute and will provide the provider with a written determination stating the reasons for the determination.
Non-Contracted Provider Dispute Resolution Process For CMS Medicare Advantage Plan Members
A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the Medicare member regardless of the outcome of the appeal. The health plan cannot undertake a review until or unless such form/documentation is obtained.
Download details of the CMS Non-Contracted Provider Dispute Process
Verification Issues on Member Eligibility
Contact Member Services.
Pharmacy Services
Drug List
Senior Program (HMO) Comprehensive Formulary 2025
Senior Program (HMO) Comprehensive Formulary 2026
Senior Value Program (HMO) Comprehensive Formulary 2025
Senior Value Program (HMO) Comprehensive Formulary 2026
Senior Select Program (HMO D-SNP) Comprehensive Formulary 2025
Senior Select Program (HMO D-SNP) Comprehensive Formulary 2026
Plan Formulary & Pharmacy
To check a CCHP plan drug list, a comprehensive formulary, and pharmacy can be found below under CCHP Drug List. If you have any questions, please contact Member Services.
Effective July 1, 2014, the new Prescription Drug Prior Authorization Request Form is required for non-Medicare plans. View Section 1300.67.241 to read the complete DMHC regulations specifying the process.
Prescription Drug Prior Authorization Request Form
Please note, this form should also be used to request Prior Authorizations for Medicare plans.
Pharmacy Locator & Drug Cost Preview Tool
Training and Compliance
Fraud and Abuse Training
The Centers for Medicare and Medicaid Services (CMS) requires annual fraud, waste, and abuse training for organizations providing health, prescription drug, or administrative services to Medicare Advantage (MA) or Prescription Drug Plan (PDP) enrollees on behalf of a health plan. Providers must be knowledgeable about Federal requirements and information regarding fraud, waste, and abuse.
Provider Manual
Contact Us
Report Provider Directory Changes and Inaccuracies
If you find any inaccuracies in the provider information on our website, please contact us:
Phone: 1-415-955-8800 (Press 2 for Providers)
Email: provider.relations@cchphealthplan.com
Online: Contact Us Form
Contact Us
If you have any additional questions, please email us at provider.relations@cchphealthplan.com.