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.
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