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Providers

Becoming a CCHP Provider

CCHP is a health maintenance organization (or HMO) delivering full-suite of quality health plan coverage to over 23,000 Members. Our service area includes San Francisco and San Mateo counties. We are committed to serving our community and are devoted to delivering the highest quality health plan to the people and organizations we serve. We consider our health care providers as our customers and vital partners in serving our Members.

little girl seeing doctor with mom.
Welcome

More about CCHP

CCHP is a California licensed Knox-Keene health plan and offers a variety of commercial products for small and large group employers as well as products for individuals. In addition, CCHP is contracted with the Centers for Medicare and Medicaid Services (CMS) to offer a Medicare Advantage HMO plan (Part C), a Medicare Advantage Special Needs Program (HMO D-SNP), and an integrated Medicare Advantage Prescription Drug Plan (Part D). CCHP’s Senior Program (HMO) is for people with Medicare Parts A and B. CCHP’s Senior Select Program (HMO D-SNP, Special Needs Plan) is for people with Medi-Cal and Medicare Parts A and B.

Already a CCHP Provider?

If you are already one of thousands working with CCHP, your Provider resources can be found below.

CCHP Provider Portal

What can you do in the provider portal?

  • Check a patient’s eligibility
  • Check a patient’s claims submissions, status, denial reasons
  • View patient’s health plan benefits and summaries
  • View patient’s healthcare claims and deductible/out of pocket balances
  • Find in-network healthcare providers

Provider Resources

Provider-based Inquiries

If you need assistance with various matters such as provider customer support, utilization management inquiries, data/analytics inquiries, billing inquiries, provider IT issues, or any other related inquiries, please email us at [email protected].

*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 [email protected].
*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.

Verification Issues on Member 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.

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 1-628-228-3214 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

Download the Waiver of Liability Statement

Provider Manual

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.

Medicare Fraud, Waste and Abuse and Compliance Training

Special Needs Plans Training

Report Provider Directory Changes and Inaccuracies

If you find any inaccuracies in the provider information on our website, please contact us:
Phone: 1-628-228-3485
Email: [email protected]
Online: Contact Us Form

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.

Drug List

Message from CMS

Notice of Changes