The provider must resubmit an amended dispute along with the missing information within the time frame for dispute submissions and the amended dispute must include the information requested and required to make the dispute complete. If the provider dispute does not include the required submission elements as outlined above, the dispute is returned to the provider along with a written statement requesting the missing information necessary to resolve the dispute. If the provider dispute involves a member, the dispute must include the member's name, ID number, a clear explanation of the disputed item, the date of service, billed and paid amounts, and the provider's position.Īll provider disputes and supporting information must be submitted to: Line of Business When a provider submits a dispute on behalf of a member, the provider is considered to be assisting the member with his or her member appeal. If the dispute is not about a claim, a clear explanation of the issue and the basis of the provider's position.Ī provider dispute that is submitted on behalf of a member is processed through the member appeal process.If the dispute is regarding a claim or a request for reimbursement of an overpayment of a claim, the dispute must include a clear identification of the disputed item, the date of service, and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect.Additional information required includes: The provider dispute must include the provider's name, ID number, contact information including telephone number, and the same number assigned to the original claim.
Provider Dispute Resolution Request Form – All other Commercial and Medi-Cal (PDF).Provider Dispute Resolution Request Form – IFP (PDF).If the dispute is for multiple, substantially similar claims, complete the spreadsheet on page 2 of the Provider Dispute Resolution Request Form. When submitting a provider dispute, a provider should use a Provider Dispute Resolution Request form. If the provider does not receive a claim determination from Health Net, a dispute concerning the claim must be submitted within 365 days after the statutory time frame applicable to Health Net for contesting or denying the claim has expired. Health Net accepts disputes from providers if they are submitted within 365 days of receipt of Health Net's decision (for example, Health Net's Remittance Advice (RA) indicating a claim was denied or adjusted), except as described below. Seeks resolution of a billing determination or other contractual dispute.
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