STAGE DEV MAY, 2013

CCHP Providers Dispute Process

Provider Dispute Resolution Process

CCHP has a Provider Dispute Resolution (PDR) process that ensures provider disputes are handled in a fast, fair and cost effective manner.

A provider dispute is a written notice from a provider that:

  • Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested, or
  • Challenges a request for reimbursement for an overpayment of a claim, or
  • Seeks resolution of a billing determination or other contractual dispute.

How to Submit Provider Disputes

Providers must use a Provider Dispute Resolution and Appeal Request Form (PDF)*.

You may download Instructions for Submitting Provider Disputes (PDF)* or call CCHP Provider Relations at 1-415-955-8800, ext. 3214 for assistance.

Disputes can be mailed to:

Chinese Community Health Plan
Attention: Provider Dispute Resolution Area
445 Grant Avenue, Suite 700
San Francisco, CA 94108

Disputes can be faxed to: 1-415-955-8815

Resolution Timeframe

CCHP will resolve each provider dispute within 45 business days following receipt of the dispute, and will provide the provider with a written determination stating the reasons for the determination.

Non-Contracted Provider Dispute Resolution Process For CMS Medicare Advantage Plan Members

A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the Medicare member regardless of the outcome of the appeal. The health plan cannot undertake a review until or unless such form/documentation is obtained.

Download details of the CMS Non-Contracted Provider Dispute Process here.

Download the Waiver of Liability Statement here.