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Providers

Become a CCHP provider, get references for plan coverages, or do a quick Eligibility & Claims Inquiry with our Provider Resource page.

Welcome CCHP 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.

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.

For questions, please contact Provider Network Management at 1-415-955-8800 #3474.

Already a CCHP Provider?

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

CCHP Provider Portal

Eligibility & Claims Inquiry

What can you do in the provider portal?
  • Check a patient’s Eligibility
  • Check a patient’s Claims Status
  • View patient’s health plan benefits and summaries
  • View patient’s healthcare claims and deductible/out of pocket balances
  • Find in-network healthcare providers

For general provider-based inquiries, such as:

  • General provider customer support
  • General utilization management inquiries
  • Data/analytics inquiries
  • Billing inquiries
  • General provider IT issues
  • Other provider inquiries/questions

Please contact us at Provider.Services@cchphealthplan.com.

Please access the Provider Portal to review claims submissions and look up status, payment amounts and denial reasons.  After reviewing claims on the Provider Portal, if you still have questions or need additional information pertaining to:

  • Claim denial reason
  • Claim payment amount
  • EOP requests

Please contact us at providerinquiry@cchphealthplan.com.

 

Inquiries will be acknowledged within 5 business days, triaged, sent to the appropriate CCHP team for review.  Status updates will be provided for managed inquiries.

For verification issues on member eligibility, please contact:

1-888-775-7888 (Toll free)
1-415-834-2118 (Local)
Monday – Saturday: 9 a.m. – 5 p.m.

memberservices@cchphealthplan.com

Provider Resources

Filing Claims

Submitting Claims Electronically

CCHP prefers claims be submitted electronically. For information, please call our Member Services at 1-415-834-2118.

 

Submitting Paper Claims

All paper claims must be submitted using a CMS 1500 form (for professional providers) and a UB-92 form (for institutional providers).

 

Send paper claims to:

Chinese Community Health Plan

Claims Department

Post Office Box 1599

San Leandro, CA 94577

CCHP 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 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 (PDF).

 

You may download Instructions for Submitting Provider Disputes (PDF) or call CCHP Provider Relations at 1-415-955-8800, ext. 3214 for assistance.

 

Disputes can be mailed to:

Chinese Community Health Plan

Attention: Provider Dispute Resolution Area

445 Grant Avenue, Suite 700

San Francisco, CA 94108

 

Disputes can also be 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 (PDF).

Download the Waiver of Liability Statement (PDF).

CCHP Provider Manual

You can download your very own copy of CCHP Provider Manual:

CCHP Provider Manual – Revised 6/29/20.

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 with the federal requirements and information regarding fraud, waste and abuse. Please take a moment to go over the provided information in the PDF file link below.

Medicare Fraud, Waste and Abuse and Compliance Training (PDF).

Special Needs Plans Training

Report Provider Directory Changes and Inaccuracies

Please call, email or submit form if you find any inaccuracies with the provider information on our website. You can also use this page to report any changes in the provider’s information such as phone number, language, and location.

  1. Telephone: 1-415-955-8834
  2. Email: pic@cchphealthplan.com
  3. Online Form

CCHP 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) (PDF) to read the complete DMHC regulations specifying the process.

(New) Prescription Drug Prior Authorization Request Form (PDF) (Uploaded 02/2018)

Please note, this form should also be used to request Prior Authorizations for Medicare plans.

CCHP Drug List

Formulary for Individual, Family and Covered CA

 

CCHP Pharmaceutical Management Procedures (PDF)

 

Formulary (List of Covered Drugs) for Commercial Plans

(No changes made since 3/2023)

 

CCHP Pharmacy Directory – All Plans (PDF)

(No changes made since 1/2023)

 

CCHP Senior Program (HMO)

CCHP Senior Program (HMO) Comprehensive Formulary (PDF) 2022, 2023

 

CCHP Senior Value Program (HMO)

CCHP Senior Select Program (HMO) Comprehensive Formulary (PDF) 2022, 2023

 

CCHP Senior Select Program (HMO D-SNP)

CCHP Senior Select Program (HMO SNP) Comprehensive Formulary (PDF) 2022, 2023

 

Pharmacy Locator

Message from CMS

NEW Notice of Changes

Notice of Change to Provider Compensation (Effective April 1, 2022 and July 1, 2022)

NEW CAHPS Survey