Provider dispute and resolution policy and procedures
Medi-Cal providers have 365 days from the health plan’s action or the plan’s capitated provider's action or, in the case of inaction, to submit a written dispute to Blue Shield of California Promise Health Plan's Provider Dispute and Resolution Department. Disputes may pertain to the authorization or denial of a service; the processing, payment or nonpayment of a claim; capitation issues; or other issues.
Before submitting a dispute
The following should be submitted to the Claims Department, and not to the Provider Dispute and Resolution Department:
- Corrected claims requested by the Claims Department, with reference to a Remittance Advice Notice
- Claims being submitted for retroactive review (after services have been provided)
- Medical records requested by the Claims Department
Please refrain from sending duplicate disputes, as they slow down our efforts to achieve closure. We encourage you to check the latest status of your appeals on Provider Connection.
Before submitting a formal dispute, please direct concerns to the Provider Services Department at (800) 468-9935, 6 a.m. to 6:30 p.m., Monday through Friday. Our Provider Services team can address many questions very quickly.
Submitting a dispute
All disputes must be submitted in writing, either online via Provider Connection or by postal mail. A claim number is required for a dispute to be filed online.
To dispute a claim payment by postal mail, please submit the following request form to the Blue Shield Promise Provider Dispute and Resolution Department.
Provider Dispute Resolution Request Form (PDF, 358 KB)
Mail disputes to:
Blue Shield of California Promise Health Plan
ATTN: FirstSource – PHP PDR
265 Airpark Blvd Ste 100
Chico, CA 95973
What happens next?
Upon receipt, each dispute is logged on the Provider Dispute and Resolution database. Disputes are acknowledged within two (2) working days for disputes submitted online via Provider Connection, and within 15 working days for disputes submitted via mail.
Any provider dispute submitted on behalf of a member will be handled through the member grievance and/or appeal process.
Blue Shield Promise will send a written closure letter with the resolution to the provider within 45 working days of receipt of the provider dispute. Blue Shield Promise will retain all documentation related to the peer review in accordance with Section 53310 of the California Code of Regulation. All files shall be maintained for up to ten years.
First level appeal for Medi-Cal providers
A provider may appeal the decision made at Blue Shield Promise. Blue Shield Promise will refer clinical provider appeals and other appropriate cases for professional peer review.
When the appeal is referred to professional peer review:
- All parties concerned shall be notified that a referral has been made to professional peer review and that a final determination may require up to 45 working days from the acknowledgement of the receipt of the dispute.
- The professional peer review shall make its evaluation and submit its findings and recommendations to the plan and the provider within 45 working days after the receipt of the dispute and all background information supplied.
- Blue Shield Promise, after taking into consideration the findings and recommendations of the professional peer review, shall send a written closing letter outlining its conclusions within 45 working days of receipt of the provider appeal. Language in the letter will include the next appeal steps the provider can take with the issue.
Blue Shield Promise shall retain all documentation related to the peer review in accordance with section 53310 of the California Code of Regulation. All files shall be maintained for a minimum of five years.
Second level appeal for Medi-Cal providers
For detailed information on second-level appeals, please review the Medi-Cal Provider Manual.
Find the forms you need for authorizations, referrals, service requests, EFT enrollment, and provider disputes.
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