Medi-Cal provider disputes and resolution policy and procedures

Medi-Cal providers have 365 days from the health plan’s action or the plan’s capitated provider's action or, in the case of inaction, to submit a written dispute to Blue Shield of California Promise Health Plan's Provider Dispute and Resolution (PDR) Department. Disputes may pertain to such issues as the authorization or denial of a service or the processing, payment or nonpayment of a claim, capitation issues or other issues.

• All written formal disputes will be responded to in writing.
• Upon receipt of the written dispute specifying the issue of concern, it will be logged on the Provider Dispute and Resolution database.
• An acknowledgement letter will be sent to the provider within 15 working days of receiving the paper dispute.
   

Any provider dispute submitted on behalf of a member will be handled through the member grievance and/or appeal process.

Blue Shield Promise shall send a written closure letter with the resolution to the provider within 45 working days of receipt of the provider dispute. Blue Shield Promise shall retain all documentation related to the peer review in accordance with Section 53310 of the California Code of Regulation. All files shall be maintained for up to ten years.

First level appeal for Medi-Cal providers
A provider may appeal the decision made at Blue Shield Promise. Blue Shield Promise will refer clinical provider appeals and other appropriate cases for professional peer review.

When the appeal is referred to professional peer review:

• All parties concerned shall be notified that a referral has been made to professional peer review and that a final determination may require up to 45 working days from the acknowledgement of the receipt of the dispute.
  
• The professional peer review shall make its evaluation and submit its findings and recommendations to the Plan and the Provider within 45 working days after the receipt of the dispute and all background information supplied.
  
• Blue Shield Promise, after taking into consideration the findings and recommendations of the professional peer review, shall send a written closing letter outlining its conclusions within 45 working days of receipt of the provider appeal. Language in the letter will include the next appeal steps the provider can take with the issue.
   

Blue Shield Promise shall retain all documentation related to the peer review in accordance with section 53310 of the California Code of Regulation. All files shall be maintained for a minimum of five years.
 

Second level appeal for Medi-Cal providers
For detailed information on second-level appeals, please review the Medi-Cal Provider Manual.