Dispute review process and guidelines

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.

The dispute process is not intended to address claim corrections, requests for claim information, or inquiries about claim decisions, procedures, and payment rules.

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. 

Providers can easily start the dispute process online. 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. 

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.  

Medicare disputes are resolved within 60 calendar days of receipt. 

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. 

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.

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. 

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) informs providers of the availability of Blue Shield's Provider Dispute Resolution Process and provides 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 included in 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.

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. 

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 or bulk 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 (a health plan other than 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. Contact us for inquiries.

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.