Provider disputes and resolution policy and procedures

Provider questions, concerns, and disputes

 

Providers can voice questions and concerns to the Blue Shield of California Promise Health Plan Provider Services Department by calling, mailing a letter, sending an email, or visiting in person. A provider network administrator can address many of these questions and concerns very quickly.

Providers who are submitting corrected claims that the Blue Shield Promise Claims Department requested should submit the corrected claims directly to the claims department, with a reference to the Remittance Advice Notice received. 

Providers who are submitting claims for retroactive review (review after the services have been provided) should submit the claims directly to the claims department and not to the Provider Dispute and Resolution Department. If the Claims Department requested that you send medical records, please submit your response to the claims department and not to the Provider Dispute and Resolution Department. 

If a provider would like to appeal or dispute a claim payment, the provider must submit it in writing by mail or fax to the Blue Shield Promise Provider Dispute and Resolution Department. If a provider attempts to file a dispute by phone, Blue Shield Promise will assist the provider in filing the dispute in writing by physical or electronic means.  All appeals and disputes are entered in the Provider Dispute Database for investigation, and providers will receive a written response.

Provider Dispute Resolution Request Form (PDF, 522 KB)

Waiver of Liability Statement (PDF, 328 KB)

Medicare non-contracted providers should complete and include in their appeal a fully executed Waiver of Liability (WOL) Statement.

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

Medi-Cal provider dispute and resolution policy and procedures

Learn how to file an appeal or dispute as a Medi-Cal provider.

Review Medi-Cal provider disputes policy and procedure

Cal MediConnect provider dispute and resolution policy and procedures

Read about the appeals process as either a contracted or non-contracted Cal MediConnect provider.

Learn more

Forms

Find the forms you need for authorizations, referrals, service requests, EFT enrollment, and provider disputes.

Find forms

Health Care Options: 1-844-580-7272, de lunes a viernes, de 8:00 a. m. - a 6:00 p. m. Los usuarios del sistema TTY deben llamar al 1-800-430-7077.

Para obtener información sobre Blue Shield Promise Cal MediConnect Plan y otras opciones de Cal MediConnect para la atención de su salud, comuníquese con el Department of Health Care Services (Departamento de Servicios de Atención de la Salud) al 1-800-430-4263 (TTY: 1-800-735-2922) o visite la página https://www.healthcareoptions.dhcs.ca.gov/.

Blue Shield of California Promise Health Plan es una organización de atención administrada que pertenece completamente a Blue Shield of California, y que ofrece Medi-Cal, Cal MediConnect, Medicare Advantage HMO y Dual Eligible Special Needs Plans (D-SNP, Planes de necesidades especiales con doble elegibilidad).

© 2002-2023. California Physicians’ Service DBA Blue Shield of California Promise Health Plan. Todos los derechos reservados.

California Physicians’ Service DBA Blue Shield of California Promise Health Plan es un licenciatario independiente de Blue Shield Association..

Blue Shield of California Promise Health Plan es un plan HMO y un plan HMO D-SNP que tiene un contrato con Medicare y un contrato con el Programa Medicaid del Estado de California. La inscripción en Blue Shield of California Promise Health Plan depende de la renovación del contrato.

Las redes de proveedores pueden cambiar en cualquier momento.

Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

Blue Shield of California Promise Health Plan cumple con las leyes estatales y las leyes federales de derechos civiles vigentes, y no discrimina por motivos de raza, color, país de origen, ascedencial, religión, sexo, estado civil, genero, identidad de genero, orientación sexual, edad ni discapacidad.

Blue Shield of California Promise Health Plan 遵循適用的州法律和聯邦公民權利法律，並且不以種族、膚色、原國籍、血統、宗教、性別、婚姻 狀況、性別認同、性取向、年齡或殘障為由而進行歧視。

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