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Medi-Cal Dispute Process

Medi-Cal Contracted Payment Dispute (PDR) Mechanism

If you dispute any denial, adjustment or contested claim contained in this EOB, please submit in writing your provider dispute to the Claims Dispute Resolution Division. Your dispute must contain the following: Provider name, provider identification number, (NPI) provider contact information, a clear identification of the disputed claim, date of service and a clear explanation of the basis upon which you believe the payment amounts, contested item, denial or other action is incorrect. If the dispute is not about a claim, a clear explanation of the issue and your position thereon must be included. Disputes must be submitted within 365 days from the date of the EOB. If you have any questions regarding our PDR Mechanism, please call our Claims Department at 714-246-8600.

Contested Claims

Denied Claims

Please submit claims processed as contested for additional information as a corrected claim to:

CalOptima Claims
Attn: Contested Claims
P.O. Box 11037
Orange, CA 92856

Please submit a Provider Dispute for resolution of denied claims to:

CalOptima Claims
Attn: Provider Resolution Unit
P.O. Box 11037
Orange, CA 92856


Provider paid at contracted rates; all services are inclusive for contracted physicians paid at a case rate.

Please note: State Law prohibits contracted physicians balance billing members for covered services. These prohibitions supersede any agreement that the member may have signed at the time services were provided.

OneCare Dispute/Appeals Process

OneCare Contracted Payment Dispute (PDR) Mechanism

If you dispute any denial, adjustment or contested claim contained in this EOB, please submit in writing your provider dispute to the Claims Dispute Resolution Division. Your dispute must contain the following: Provider name, provider identification number, (NPI) provider contact information, a clear identification of the disputed claim, date of service and a clear explanation of the basis upon which you believe the payment amounts, contested item, denial or other action is incorrect. If the dispute is not about a claim, a clear explanation of the issue and your position thereon must be included. Disputes must be submitted within 365 days from the date of the EOB. If you have any questions regarding our PDR mechanism, please call our Claims Department at 714-246-8600. Providers paid at contracted rates; all services are inclusive for contracted physicians paid at a case rate.

Please note: State Law prohibits contracted physicians balance billing members for covered services. These prohibitions supersede any agreement that the member may have signed at the time services were provided.

Medicare Payment Dispute Resolution (PDR) Mechanism for Non-Contracted Providers

Submission of level of payment dispute, a written Provider Dispute must be filed within 120 calendar days after the notice of initial determination.

The United States Code of Federal Regulations, 42 CFR 1001.1901, effect of an Office of Inspector General (OIG) inclusion from Federal health care programs is that no Federal health care program payment may be made for any items or services (1) furnished by an excluded individual or entity, or (2) directed or prescribed by an excluded physician.

Federal Sequestration Order requires 2% payment reduction for Medicare program services to non-contracted providers effective 04/01/2013.

Dispute Mailing Address

One Care Disputes
PO Box 11037
Orange, Ca. 92856


Medicare Non-Contracted Provider Appeals Process

Non-Contracted providers have the right to request reconsideration for denial of payment within 60 calendar days from the remittance notification date. A signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal is required and can be found at CalOptima’s website, under Forms, Waiver of Liability Statement-One Care (HMO SNP), at the following link: https://www.caloptima.org/Home/Providers/CommonForms.aspx

The reconsideration/appeal request to include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s argument for reimbursement, and must mail or fax the reconsideration to the plan at:

CalOptima Grievance and Appeals Resolution Services
505 City Parkway West
Orange, CA 92868
Fax: 1-714-481-6499

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