Cal MediConnect provider disputes and resolution policy and procedures

Effective January 1, 2023, Cal MediConnect plans were discontinued throughout California. Blue Shield Promise Cal MediConnect members in Los Angeles and San Diego counties were transitioned to the Blue Shield TotalDual (HMO D-SNP) plan. 

The payment rules for Cal MediConnect work the same for Medicare Advantage organizations (MAOs) and Medi-Cal, where the MAO is the primary payer and Medi-Cal the secondary payer. If the benefit or service is not covered under the MAO, but is covered under Medi-Cal, then Blue Shield Promise will coordinate the payment accordingly. The dispute/appeal process for most benefits is generally the same as for Medicare contracted or non-contracted providers.

In this section:

Cal MediConnect contracted provider dispute policy and procedures
Cal MediConnect non-contracted provider disputes
Cal MediConnect non-contracted provider appeals

Cal MediConnect contracted provider dispute policy and procedures

Cal MediConnect contracted provider disputes must be submitted to Blue Shield Promise, at the address listed below, within 365 calendar days from the plan’s action or the plan’s capitated provider’s action or inaction.

Submission

When submitting a contracted provider dispute, a provider must complete the following forms and documentation:

• Fully completed Provider dispute resolution request form (PDF, 522 KB)
• If the dispute is for multiple, substantially similar claims, submit a Provider dispute resolution request spreadsheet (PDF, 115 KB)
   

The provider dispute must include all of the following information:

• Provider's name
• Provider's national provider identifier number
• Contact information (address and phone number)
• Copy of the emergency operations plan (EOP), remittance advice (RA), or other evidence reflecting the concerning claim
• Copy of the original claim and the claim number
• Date of service
• Amount of the dispute
• Clear explanation what the dispute is regarding and/or a clear explanation of the issue and the basis of the provider's position
• Medical records or any additional evidence that can support the dispute or request

Please submit your provider dispute by mailing it to the following:

 Blue Shield of California Promise Health Plan
      ATTN: Provider Dispute & Resolution Department
      PO Box 3829
      Montebello, CA 90640

Procedure

The Provider Dispute and Resolution (PDR) Department will mail out a PDR Acknowledgment Letter within 15 working days from the date of receipt of the provider dispute. The PDR Department will review and prepare a written explanation, no later than 60 calendar days to the provider from the date it receives the request for a payment dispute.

If you have any questions or require additional information regarding your provider dispute, please contact our Provider Dispute Resolution (PDR) Department. If you have received a PDR Case ID number please reference it when contact us.

  PDR Phone: (800) 468-9935, 8 a.m. to 5 p.m., Monday through Friday.

Dispute policies and procedures for Blue Shield Promise Cal MediConnect non-contracted providers

These are providers that are not contracted with Blue Shield Promise.

Non-contracted provider disputes

If you believe that the payment amount you receive for services you provided to a Blue Shield Promise member is less than the amount paid by Original Medicare or if there is a disagreement about Blue Shield Promise's decision to pay for a service different from the one billed, you have the right to dispute the payment amount by forwarding the payment dispute request to Blue Shield Promise.

Non-contracted provider claims payment disputes include instances where you may disagree with the decision to pay for a different service or level than billed. Some reasons for payment disputes are:

• Bundling issues
• Diagnosis-related group payments
• Down-coding
   

Blue Shield Promise will review your dispute and respond to you with a payment review determination decision within 60 calendar days from the date we receive your completed documentation (such as a remittance advice (RA)), and a Medicare non-contracted provider dispute request).

Submission

Cal MediConnect non-contracted provider disputes must be submitted to Blue Shield Promise within 120 calendar days after the receipt of notice of initial determination/decision.

When submitting a Cal MediConnect non-contracted provider dispute, a provider must fully complete the following forms and documentation in order for Blue Shield Promise to process the dispute timely and effectively:

• Fully completed provider dispute resolution request form (PDF, 522 KB)
• If the dispute is for multiple, substantially similar claims, submit a provider dispute resolution request spreadsheet (PDF, 115 KB) with the Provider dispute resolution request form.
   

The provider dispute must include all of the following information:

• Provider's name
• Provider national provider identifier number
• Contact information (address and phone number)
• Copy of the emergency operations plan (EOP), remittance advice (RA), or other evidence reflecting the concerning claim
• Copy of the claim or a new claim (if not previously submitted)
• Claim number
• Date of service
• Amount of the dispute
• Clear explanation what the dispute is regarding and/or a clear explanation of the issue and the basis of the provider's position
• Medical records or any additional evidence that can support the appeal request
   

Please submit your provider dispute and supporting documentation by mailing it to the following address:

 Blue Shield of California Promise Health Plan
      ATTN: Provider Dispute & Resolution Department
      PO Box 3829
      Montebello, CA 90640

Procedure

The Provider Dispute and Resolution (PDR) Department will mail a PDR acknowledgment letter within 15 working days from the date of receiving the provider dispute. The PDR Department will review and prepare a written explanation, which will be sent to the provider no later than 60 calendar days from the date following receipt of your request.

If Blue Shield Promise agrees with your position, we will pay you the correct amount, including any interest that is due. We will also inform you in writing if we deny (uphold) our initial claims payment to you. If you believe that this determination is not correct, you have the right to file a complaint with Medicare at 1-800-MEDICARE / (800) 633-4227.

If you have any questions or require additional information regarding your provider dispute, please contact our Provider Dispute Resolution (PDR) Department. If you have received a PDR Case ID number, please reference it when contacting us.

  Phone: (800) 544-0088 8 a.m. to 5 p.m., seven days a week from October 1 through March 31, and 8 a.m. to 8 p.m., Monday through Friday

Non-contracted provider appeals

A non-contracted Cal MediConnect provider may submit an appeal if they received zero payment for services provided to a Blue Shield Promise Cal MediConnect member.

Blue Shield Promise is a Medicare Advantage organization (MAO) and as such, is regulated by the Centers for Medicare and Medicaid (CMS). In accordance with CMS regulations, providers who are not contracted with MAOs may file a post-service standard appeal for a claim payment that has been denied (zero payment), in whole or in part.

In addition, CMS regulations state that the Medicare non-contracted provider must complete and sign a Waiver of Liability (WOL) statement. By signing the WOL, you waive the right to collect payment from the member, with the exception of any applicable cost sharing, regardless of the determination made on the appeal.

The Medicare non-contract provider appeal process is available to you if:

• You do not have a Medicare contract with Blue Shield Promise
• You received zero payment for services you provided to a Blue Shield Promise Medicare member
   

The following are examples of Medicare non-contracted provider appeals:

• Benefit determinations
• Medically necessary issues
• Coverage issues related to national or local coverage decisions
   

Blue Shield Promise will review your provider appeal and respond to you with a payment review determination decision within 60 calendar days from the date we receive your completed documentation (such as a remittance advice (RA), and a Medicare non-contracted provider appeal request).

Submission

Medicare non-contracted provider appeals must be submitted in writing to Blue Shield Promise within 60 calendar days after the receipt of notice of initial denial determination/decision.

When submitting an appeal, a provider must fully complete the following forms and documentation:

• Fully completed Provider dispute resolution request form (PDF, 522 KB). This form must be signed by the initiator or their representative.
• If the dispute is for multiple, substantially similar claims, submit a Provider dispute resolution request spreadsheet (PDF, 115 KB) with the Provider dispute resolution request form.
• Completed and signed Waiver of Liability statement (PDF, 329 KB)
   

The provider dispute must include all of this information:

• Provider's name
• Provider national provider identifier number
• Contact information (address and phone number)
• Copy of the emergency operations plan (EOP), remittance advice (RA), or other evidence reflecting the concerning claim
• Copy of the claim or a new claim (if not previously submitted)
• Claim number
• Date of service
• Amount of the dispute
• Clear explanation what the dispute is regarding and/or a clear explanation of the issue and the basis of the provider's position
• Medical records or any additional evidence that can support the appeal request
   

The member's Medicare health insurance claim number (HICN) must be included on the Waiver of Liability (WOL) statement. Note: Do not insert any other reference or identification number in the HICN area of the WOL.

Please submit your provider appeal by mailing all of the appropriate documentation to the following address:

 Blue Shield of California Promise Health Plan
      ATTN: Provider Dispute & Resolution Department
      PO Box 3829
      Montebello, CA 90640

Procedure

Response time
The Provider Dispute and Resolution (PDR) Department will mail a PDR Acknowledgment Letter within 15 working days from the date of receiving the provider dispute.

Blue Shield Promise’s response will be within 60 calendar days from the date your request for an appeal and signed WOL are received. If the WOL is not included, we will notify you of this missing information. You must provide Blue Shield Promise with a completed and signed WOL before we can commence with the review of your appeal. If the WOL is not received within 60 calendar days of Blue Shield Promise’s receipt of the provider appeal, your request will be dismissed. Blue Shield Promise will send you a Notice of Appeal Dismissal, advising you of the reason and explaining your right to request an Independent Review Entity (IRE) review of the dismissal within 60 calendar days after you receive Blue Shield Promise’s written notice of dismissal.

If Blue Shield Promise decision is upheld
If Blue Shield Promise upholds its decision (continues to deny an appeal, in whole or in part), we will provide you with written notice of our payment review determination decision within 60 calendar days from the date we receive your completed appeal. Blue Shield Promise will then automatically forward your appeal and the provider appeal denial case to the CMS Independent Review Entity (IRE), MAXIMUS Federal Services. In the denial notification it will provide additional notification of appeal rights available to the provider, including but not limited to a reconsideration by the CMS Independent Review Entity (IRE), MAXIMUS Federal Services.

If Blue Shield Promise decision is overturned
If Blue Shield Promise overturns its decision (agrees to provide payment, in whole or in part), we will notify you in writing and pay you the correct amount including any interest. The review of your appeal will occur within 60 calendar days from the date we received your completed appeal.

If you have any questions or require additional information regarding your provider dispute, please contact our Provider Dispute Resolution (PDR) Department. If you have received a PDR Case ID number, please reference it when contact us.

  Phone: (800) 468-9935, 8 a.m. to 5 p.m., Monday through Friday