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.
Cal MediConnect provider dispute and resolution policy and procedures
Read about the appeals process as either a contracted or non-contracted Cal MediConnect provider.
Forms
Find the forms you need for authorizations, referrals, service requests, EFT enrollment, and provider disputes.