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Claim issues & disputes

Find resources and information here regarding provider disputes, including an overview of the dispute process, instructions, and our online dispute form.

Blue Shield of California is committed to providing a fair and transparent Provider Dispute Resolution Process. However, the dispute process is not intended to address claim corrections, requests for claim information, or inquiries about claim decisions, procedures, and payment rules.

We may be able to help remedy a claim issue before you file a formal dispute. If your claim has been denied or not paid in full, here are your options:

  • Correct a claim
    Submit corrected claims within 30 working days of receiving a request for missing or additional information.
  • Contact Provider Services
    If you have questions about a specific claim, contact Blue Shield of California Provider Services.
  • Make an inquiry
    Inquiries are requests made to a member’s customer service department to clarify claim decisions, procedures, and payments. They may alter original decisions.

If we’re not able to resolve your claim issue and you consider it necessary to file a dispute, please start with the online form.

File a dispute online

Have a question? See FAQs

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File a dispute by mail

Find paper dispute resolution forms, filing instructions, and mailing addresses. 

Get forms and instructions

Submitted disputes

Get information about disputes you’ve submitted within the last 5 years.

View my disputes

Disputes covered by the No Surprise Billing Act: The act requires that insurers and out-of-network providers resolve medical service and emergency room facility claims via open negotiation. Submit the Open Negotiation Notice form to initiate the process.

What to expect

To file a dispute online, you’ll need a claim number or multiple claim numbers if you’re bundling claims, an email where we can reach you, and relevant supporting documents.

Acknowledgement

  • For disputes submitted online, we’ll notify you via email within 2 working days when a letter acknowledging receipt of the dispute is ready to view on Provider Connection. 
  • For disputes submitted by mail, we’ll notify you with a letter acknowledging receipt of the dispute within 15 working days

Resolution

  • We resolve disputes within 45 working days of receiving them. 
  • Disputes that are returned due to missing information are resolved within 45 working days of receiving an amended dispute with missing information. 
  • If the resolution of a dispute results in funds due to a provider, we’ll issue a payment, including interest when applicable, within 5 working days of the date of the written notice of the dispute resolution.  
  • In most cases, if you disagree with a determination, you have 65 working days to start a final dispute.

Find completed dispute forms, supporting documents, and acknowledgement and determination letters to view and download on Provider Connection. 

Learn more about the dispute process

  • What is a dispute?

    A dispute is usually a request to reconsider a claim that has been denied, adjusted (paid at less than billed charges), or contested. Providers may also dispute billing determinations, such as procedure codes, allowances, and the bundling and unbundling of claims; administrative policies, procedures, and terminations; reimbursement requests for overpayments; and any contract issues.

  • When can I file a dispute?

    Initial disputes 

    Initial disputes must be submitted within 365 days, or the time specified in the provider's contract, whichever is greater, of Blue Shield's date of contest, denial, notice, or payment. 

    If a dispute involves a lack of a decision, it must be submitted within 365 days, or the time specified in the provider's contract, whichever is greater, after the time for contesting or denying a claim has expired. 

    Disputes related to demonstrable and unfair payment patterns must be submitted within the timeframes indicated above, based on the date of the most recent action or inaction by Blue Shield. 

    Final disputes 

    Final disputes must be submitted within 65 working days of Blue Shield's initial determination. 

    Timely filing 

    If a provider or capitated entity fails to submit a dispute within the required timeframes, the provider or capitated entity: 

    • Waives the right for any remedies to pursue the matter further 
    • May not initiate a demand for arbitration or other legal action against Blue Shield 
    • May not pursue additional payment from the member 

    In instances where the provider's contract specifies timeframes that are greater than those in Blue Shield's Provider Dispute Resolution Process, the provider's contract takes precedence. 

    Blue Shield will review a dispute submitted outside of the specified timeframes if the provider's contract includes a good cause clause for untimely dispute submissions. 

  • How can I file a dispute?

    Providers can easily start the dispute process using the online form. If a claim decision cannot be disputed online for any reason, providers can start the dispute process through a written request by mail. To ensure a considered determination, providers are asked to clearly describe the rationale for their dispute and what outcome they hope will resolve it. 

  • How long does the dispute process take?

    Blue Shield resolves disputes within 45 working days of receipt.  

    If a dispute requires missing or additional information, Blue Shield will resolve it within 45 working days of receiving the required information.  

    Blue Shield will provide a written determination for each dispute, stating the pertinent facts and explaining the reasons for the determination. 

    The written determination of an initial dispute will notify providers and capitated entities of their right to file a final dispute. 

    If the resolution of a dispute results in added funds due to the provider, Blue Shield will issue payment, including interest when applicable, within 5 working days of the date of the resolution. 

    Contesting requests to refund an overpayment 

    Providers must submit a notice contesting Blue Shield's refund request within 30 working days of receiving a notice of overpayment. 

    The notice must include the required information for submitting a dispute as well as a clear statement indicating why the provider believes that the claim is not overpaid. 

    A notice contesting a refund request will be identified as a dispute and follow Blue Shield's Provider Dispute Resolution Process. 

    Submitting a dispute on a member’s behalf 

    Disputes submitted on a member's behalf will be treated as a member grievance and handled within the member grievance process. 

    Blue Shield will verify with the member that the provider has been authorized to submit a dispute (member grievance) on the member's behalf. 

  • What are my options after a determination is made?

    Blue Shield's Provider Dispute Resolution Process consists of two levels: Initial and Final. 

    CCR, title 28, Section 1300.71.38 requires health plans to offer a dispute process. State law does not require health plans to offer two levels. 

    Final disputes 

    Providers or capitated entities who disagree with Blue Shield's initial determination may pursue the matter further by submitting a final dispute within 65 working days of Blue Shield’s initial determination, or the time specified in the provider’s contract, whichever is greater. 

    Final disputes can be submitted online or by mail with the same required information as initial disputes.

  • What if I submit a dispute with incomplete information?

    Disputes that lack the required information will be returned to the provider or capitated entity.

    Blue Shield will return the dispute and notify the provider or capitated entity of the missing information necessary to resolve the dispute.

    The original dispute, along with the additional information identified by Blue Shield, should be resubmitted to Blue Shield within 30 working days of the provider's receipt of the notice requesting the missing information. 

    Blue Shield will not require the provider to resubmit claim information or supporting documentation that has been previously received as part of the claims adjudication process. 

  • Arbitration

    Contracted providers who disagree with Blue Shield's payment or final determination may submit the matter to binding arbitration as applicable and outlined in the provider's contract. 

    Notification of dispute rights 

    Provider contracts 

    Blue Shield informs contracting providers and capitated entities, initially upon contracting, or upon change to the Provider Dispute Resolution Process, of the procedures for submitting a provider dispute, including: 

    • Identity of the office responsible for receiving and resolving provider disputes 
    • Mailing address 
    • Telephone number 
    • Directions for filing a dispute 
    • Directions for filing bundled disputes 
    • The timeframe in which Blue Shield will acknowledge receipt of a dispute 

    The disclosures are made in contracts and online beginning January 1, 2004. 

    Explanation of Benefits 

    Explanation of Benefits (EOB) inform providers of the availability of Blue Shield's Provider Dispute Resolution Process and provide instructions for filing a dispute. 

    An EOB is sent each time Blue Shield processes a claim submitted by a provider. Information about provider disputes is available in page 2 of provider EOBs.   

    EOBs are issued to both contracting and non-contracting providers. 

    Provider manuals 

    The Provider Dispute Resolution Process has been documented since July 1, 2004 in the Hospital and Facility Guidelines, the Independent Physician and Provider Manual, and the HMO IPA/Medical Group Procedures Manual.

  • Capitated entity (IPA/Medical Group) dispute resolution requirements

    IPA/Medical Group responsibilities 

    In accordance with state law, IPA/Medical Groups are required to establish a fair, fast, cost-effective provider dispute resolution process. 

    In the event an IPA/Medical Group fails to resolve provider disputes in a timely manner, and consistent with state law, Blue Shield may assume responsibility for the administration of the IPA/Medical Group's dispute resolution mechanism. 

    Blue Shield contracts 

    Blue Shield contracts require the IPA/Medical Group to establish and maintain a fair, fast and cost-effective dispute resolution to process and resolve provider disputes. 

    The IPA/Medical Group's dispute resolution process must be in accordance with sections 1371, 1371.1, 1371.2, 1371.22, 1371.35, 1371.36, 1371.37, 1371.38, 1371.4, and 1371.5 of the Health and Safety Code, and sections 1300.71, 1300.71.38, 1300.71.4 and 1300.77.4 of the CCR, title 28. 

    Quarterly report 

    IPA/Medical Groups are required to provide a tabulated report of each provider dispute received. The report must be categorized by receipt date, and include the identification of the provider, type of dispute, disposition, and working days to resolution. 

    Each individual dispute in a bundled dispute is reported separately. 

    Provider dispute documentation 

    Upon request, the IPA/Medical Group will make available to Blue Shield, or the California Department of Managed Health Care (DMHC), all records, notes, and documents regarding their provider dispute resolution mechanism and the resolution of provider disputes. 

    Medical necessity denials 

    Blue Shield's Provider Dispute Resolution Process allows any provider that submits a dispute involving an issue of medical necessity or utilization review to the IPA/Medical Group's dispute resolution mechanism an unconditional right of appeal for that dispute.  

    Providers must submit their request to Blue Shield within 60 working days of receiving the IPA/Medical Group determination. 

  • Definitions

    Dispute 

    A dispute is usually a request to reconsider a claim that has been denied, adjusted (paid at less than billed charges), or contested. Providers may also dispute billing determinations, such as procedure codes, allowances, and the bundling and unbundling of claims; administrative policies, procedures, and terminations; reimbursement requests for overpayments; and any contract issues.  

    Dispute determination date 

    The date Blue Shield's determination in response to a dispute is electronically submitted or deposited in the U.S. mail. 

    Bundled dispute 

    A group of substantially similar claims that are individually numbered using the Blue Shield assigned Internal Control Number (ICN) to identify each claim contained in the bundled dispute. 

    Also, a group of substantially similar contractual disputes that are individually numbered using the section of the contract and sequential numbers that are cross-referenced to a document or spreadsheet.  

    Date of contest, denial, notice, or payment 

    The date Blue Shield's claim decision, or payment, is electronically transmitted (835) or deposited in the U.S. mail (Explanation of Benefits). 

    Good cause for untimely submission of claims 

    Circumstances reasonably beyond the control of the provider that prevent the timely submission of a claim are considered "good cause". 

    Examples of circumstances beyond the control of the provider, include, but are not limited to: 

    • Patient gives incorrect health coverage/insurance information (copy of an incorrect ID card) 
    • Patient is unable to provide health coverage/insurance information (patient is comatose or passes away before the information can be obtained) 
    • Natural disaster/acts of nature (fire, flood, earthquake, etc.) 
    • System-wide loss of computer data (system crash) 

    Examples of circumstances that don’t constitute "good cause": 

    • Claim is sent to the wrong carrier (Blue Cross instead of Blue Shield), but the provider has the correct health coverage/insurance information 
    • The claim is submitted in timely fashion, but Blue Shield is unable to process because the claim is incomplete (doesn’t contain the minimum data elements to enter the claim into the system, i.e., missing subscriber number) 
    • Providers have an obligation to be responsible for appropriate timely billing practices. 
    • Requests to review a claim timely filing denial because the provider believes they have good cause for the delay will be handled as a dispute. 

    Provider inquiry 

    A request for information regarding claim status, member eligibility, payment methodology rules (ClaimCheck logic, bundling/unbundling logic, multiple surgery rules), Medical Policy, coordination of benefits or third-party liability/workers compensation issues. Inquiries include submission of corrected claims. 

    Receipt date 

    The working date when a dispute is submitted online or delivered to the designated provider dispute post office box. 

    Unfair billing pattern 

    Engaging in a demonstrable and unjust pattern of bundling and unbundling or up-coding of claims, and/or other demonstrable and unjustified billing patterns. 

    Unjust or unfair payment pattern 

    Any practice, policy, or procedure that results in repeated delays in the processing and/or correct reimbursement of claims as defined by applicable regulations.

For Blue Shield of California Promise Health Plan providers

Learn about the dispute process for Blue Shield Promise Medicare, Medi-Cal, and Cal MediConnect providers.

Read Blue Shield Promise provider dispute resolution policies

Refund requests for Blue Shield of California providers

Get information on scenarios that might result in overpayments and how to process refund requests.

Learn more about refund requests

Professional fee schedule for Blue Shield of California providers

Search the professional fee schedule for Blue Shield of California allowances and learn how we establish them.

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Payment policies and rules

Read an overview of payment processing policies and rules.

Learn more about our payment policies