Provider Complaint Process

How to file a provider complaint or dispute

Medi-Cal and OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, maintain a complaint process to review and resolve provider disputes regarding claims payment, as well as utilization management decisions and other non-payment-related issues.

CalOptima Health has a single internal review process for CalOptima Health Community Network (CHCN) disputes and claims where CalOptima Health has financial responsibility, which is handled through our Grievance and Appeals Resolution Services (GARS) department. This one-level internal review provides a fast, fair and cost-effective dispute resolution mechanism to process and resolve contracted and non-contracted provider disputes and reduces the timeframe for the provider to receive a final decision by CalOptima Health.

For disputes related to a CalOptima Health-contracted health network’s claim payment, providers must submit the dispute to the appropriate health network for resolution. If the provider is not satisfied with the health network’s decision, the provider may submit a request for a second-level review by CalOptima Health’s GARS department.

The provider complaint process contains different procedures depending on whether or not the provider filing the complaint is contracted with either Medi-Cal or OneCare. To review the complete provider complaint process, see section R1 of the Provider Manual.

To guide you through the process, we have two forms to distinguish the different types of requests.

How to File a PDR Through the Provider Portal

You can submit Provider Dispute Resolutions (PDRs) for claims directly through the CalOptima Health Provider Portal, making the process faster, easier and more efficient. When a claim has been finalized, this feature enables provider portal users with access to the Claims module to submit and track claims disputes directly through the portal. This reduces administrative burden and provides greater transparency of the dispute process.

This form is for claim payment disputes related to reimbursement rates or processing of CalOptima Health claims. If a health network (HN) is responsible for payment, submit your dispute to the HN. If the HN upholds the first-level PDR, mail your second-level HN PDR, including the written determination letter provided by the HN, to the address below.

Attention: Grievance and Appeals Resolution Services
505 City Parkway West
Orange, CA 92868

If you prefer, you can continue to mail PDRs with supporting documents and a PDR form for each claim to the address above.

All corrected/modified claims will need to be sent to CalOptima Health’s Claims department via the provider portal or to the mailing address above. This form is not intended for requests related to clinical reviews for medical necessity determinations in the case of a denied authorization or OneCare Non-Contracted Provider Claim Appeals related to diagnosis code/DRG payment denials, downcoding, bundling issues, or level of care or rate of payment denials. If your request is related to a denied authorization or for a OneCare Non-Contracted Provider Claim Appeal, please mail your appeal with complete medical records and a signed Waiver of Liability to GARS.