Provider Dispute Resolution (PDR) Process for Commercial HMO Claims

The California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and a process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This information notice is intended to inform you of your rights, responsibilities, and procedures for claim payment and provider dispute resolution for commercial HMO, POS, and, where applicable, PPO products where Brown & Toland Physicians is delegated to perform claims payment and provider dispute resolution.

Definition of Provider Dispute

A provider dispute is a provider’s written notice to Brown & Toland and/or the member’s applicable health plan challenging, appealing, or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted, or contested or seeking resolution of a billing determination. In addition, a contracted provider may also submit a written notice regarding a contract dispute (or bundled group of substantially similar multiple contractual disputes that are individually numbered). Also, a provider may submit a written notice disputing a Brown & Toland request for reimbursement of an overpayment of a claim. Each provider dispute must contain, at a minimum the following information: provider’s name; provider’s identification number, provider’s contact information, and:

If the provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from Brown & Toland to a provider the following must be provided: a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect;
If the provider dispute is not about a claim, a clear explanation of the issue and the provider’s position on such issue; and
If the provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service and provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.

To submit a dispute to Brown & Toland, a provider must use a “Provider Dispute Resolution Request Form.” All contracted provider disputes must be sent to the attention of Customer Service Provider Dispute Unit using one of the following routes:

Via Mail: Brown & Toland Customer Service Provider Dispute Unit, P.O. Box 72710 Oakland, CA 94612-8910

Via email: [email protected]

Time Period for Submission of Provider Disputes

Provider disputes must be received by Brown & Toland within 365 days from Brown & Toland’s action (or the most recent action if there are multiple actions) that led to the dispute; or
In the case of Brown & Toland’s inaction, provider disputes must be received by Brown & Toland within 365 days after the provider’s time for contesting or denying a claim (or most recent claim if there are multiple claims) has expired;
Provider disputes that do not include all required information as set forth above in Section A i, ii, and iii may be returned to the submitter for completion. An amended provider dispute which includes the missing information may be submitted to Brown & Toland within thirty (30) working days of your receipt of a returned provider dispute.

Acknowledgment of Provider Disputes

Brown & Toland will acknowledge receipt of all provider disputes as follows:

Electronic: Provider disputes will be acknowledged by Brown & Toland within two (2) Working Days of the Date of Receipt by Brown & Toland.
Paper: Provider disputes will be acknowledged by Brown & Toland within fifteen (15) Working Days of the Date of Receipt by Brown & Toland.

Contact Brown & Toland Regarding Provider Disputes

All inquiries regarding the status of a provider dispute or about filing a provider dispute must be directed to Customer Service Provider Dispute Unit at: 415.972.6002.

Instructions for Filing Substantially Similar Provider Disputes

Substantially similar multiple claims, billing, or contractual disputes, may be filed in batches as a single dispute, provided that such disputes are submitted in the following format:

Please use the “Provider Dispute Resolution Form”
Please check the “Multiple ‘LIKE’ Claims” box in the Claim Information section and complete the spreadsheet.

Time Period for Resolution and Written Determination of Provider Dispute

Brown & Toland will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) Working Days after the Date of Receipt of the provider dispute or the amended contracted provider dispute.

Past Due Payments

If the provider dispute involves a claim and is determined in whole or in part in favor of the provider, Brown & Toland will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) Working Days of the issuance of the written determination.

Provider Dispute Resolution (PDR) Process for Non-contracted Provider/Medicare Advantage Claims

Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider disagrees with the Medicare Professional Fee Schedule based paid amount. To dispute a claim payment, submit a written request within 120 calendar days of the remittance notification date and include at a minimum:

A statement indicating factual or legal basis for the dispute.
A copy of the original claim.
A copy of the remittance notice showing the claim payment.
Any additional information, clinical records or documentation to support the dispute.

First Level Medicare Advantage PDR Review

Providers should send their first level Medicare Advantage PDR request to Brown & Toland.

Via Mail: Brown & Toland Customer Service Provider Dispute Unit, P.O. Box 72710 Oakland, CA 94612-8910

The “Provider Dispute Resolution Request Form” is available here.

Second Level Medicare Advantage PDR Review

Requests for a second level Medicare Advantage PDR review must be submitted directly to the health plan within 180 calendar days.

Health Plan Addresses for 2nd Level PDRs:

Aetna Medicare Part C Grievance and Appeal Unit
PO Box 14067
Lexington, KY 40512

Alignment Health Plan
P.O. Box 14012
Orange, CA 92863

Anthem Blue Cross MA
Attn: Appeals & Grievances
Mailstop: OH0204-A537
4361 Irwin Simpson Rd
Mason, OH 45040

Blue Shield of California
Appeal Resolution Office
P.O. Box 272620
Chico, CA 95927-2620

HEALTH NET of California, Inc.
Attn: Medicare Claims
P.O. Box 9030
Farmington, MO 63640-9030

SCAN Health Plan
Attention: Claims-2nd Level Appeal
P.O. Box 22698
Long Beach, CA 90801-5698
Fax: 562-426-2150

UHC – You have the right to appeal directly with MAXIMUS.

Appeals Process for Non-contracted Medicare Providers

Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination including issues related to bundling or down coding of services. To appeal a claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum:

A statement indicating factual or legal basis for appeal
A signed Waiver of Liability form (you may obtain a copy here)
A copy of the original claim
A copy of the remittance notice showing the claim denial
Any additional information, clinical records or documentation

Health Plan Addresses for Non-Contracted Appeal/Reconsideration:

Aetna Medicare Part C Grievance and Appeal Unit
PO Box 14067, Lexington, KY 40512

Alignment Health Plan Attn: Appeals Dept
P.O. Box 14010 Orange, CA 92863

SCAN Non-Contracted Provider Appeal
PO Box 22698, Long Beach, CA 90801

Wellcare by Health Net, Provider Appeal
PO Box 3060, Farmington, MO 63640-3822

Anthem Blue Cross MA
Appeals & Grievances Mailstop: OH0205-A537 4361, Irwin Simpson Rd. Mason, OH 45040

United Healthcare MA
P.O. Box 6106, Cypress, CA 90630 MS: CA124-0157

Blue Shield of California
Appeal Resolution Office
P.O. Box 272620, Chico, CA 95927-2620

If you have additional questions relating to a dispute decision made, you may contact us at:

Phone: 415-972-6002

Mail: PO Box 72710, Oakland, CA 94612-8930

Email: [email protected]

Provider Dispute Resolution Request Form

HMO Explanation of Payment

Fee Schedules

The Medicare Fee Schedule can be found online at: https://med.noridianmedicare.com/web/jeb/fees-news/fee-schedules
For questions regarding fee schedules, contact:
Altais
Attention: Physician Services Department
601 12 Street, Suite 1600
Oakland, CA 94607
Email: [email protected]