Providers | Blue Shield of California Promise Health Plan

Provider Disputes

Frequently Asked Questions (FAQs)

Provider Questions, Concerns, and Disputes

Providers can communicate questions and concerns to the Blue Shield of California Promise Health Plan Provider Services Department by telephone, e-mails, in writing, or in person. Many of these questions and concerns can be addressed very quickly by a Provider Network Administrator.

Providers who are submitting corrected claims requested by the Blue Shield of California Promise Health Plan Claims Department should submit the corrected claims directly to the claims department with a reference to the Remittance Advice notice received. Corrected claims should not be submitted to the Provider Dispute & Resolution Department unless a denial was received.

Providers who are submitting claims for retro review (review after the services have been provided) should submit these claims directly to the claims department and not to the Provider Dispute & Resolution Department. If the Claims Department has requested that you send medical records, please submit your request to the claims department and not to Provider Dispute & Resolution Department. If the Claims Department has sent you a denial letter please submit your request to the Provider Dispute & Resolution Department.

If a provider would like to appeal or dispute a claim payment it must be submitted in writing by mail or facsimile to the Blue Shield of California Promise Health Plan Provider Dispute & Resolution (PDR) Department. If a provider attempts to file a dispute via telephone, Blue Shield of California Promise Health Plan will assist the provider to file the dispute in writing by physical or electronic means. The provider appeal and/or dispute process and the Provider Dispute Form that is available on this Website. All appeals and/or disputes are entered in the Provider Dispute Database to be investigated and a response will be provided in writing.

In order to facilitate and process a provider payment issue the following instructions and processes have been made available to providers by line of business.

Medi-Cal

Medicare

Cal MediConnect

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If you enter the web site CMS (Centers for Medicare & Medicaid Services) (http://www.cms.gov), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the CMS (Centers for Medicare & Medicaid Services) web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site California Department of Health Care Services (DHCS) (https://www.healthcareoptions.dhcs.ca.gov/), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the California Department of Health Care Services (DHCS) web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site Medi-Cal Dental Program (https://www.denti-cal.ca.gov/), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the Medi-Cal Dental Program web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site Solera4me (https://www.solera4me.com/bluepromisemedicare), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the Solera4me web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site Department of Managed Healthcare (http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the Department of Managed Healthcare web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site.