Filing A Provider Complaint

Instructions For Filing a Provider Complaint

Providers must file a complaint within the designated number of calendar days from the date of decision or action that is being contested as listed below:

  Initial Complaint Second Level at CalOptima

Medi-Cal
Health Networks

365 days
(effective 1/1/04)
365 days

Medi-Cal
CalOptima Direct

365 days
(effective 1/1/04)
Not Applicable

LTC Providers

365 days
(effective 7/1/04)
Not Applicable

Healthy Families
Health Network

365 days
(effective 1/1/04)
Medical Necessity
   - 60 days
All other issues
   - 180 days

Pharmacy
Credentialing

15 days
(effective 1/1/00)
15 days
(effective 1/1/00)
Note: UM Appeals, LTC Appeals, and Claims Resubmission processes must be exhausted prior to submitting an initial complaint.


Claims Issues

Health Network: A provider must file a complaint with the member’s assigned network prior to filing a complaint with CalOptima. If not satisfied with the decision as indicated in the network’s decision letter, the Provider may file a complaint with CalOptima’s Grievance and Resolution Services Department within the designated timeline.

CalOptima Direct and/or Long Term Care: A provider must follow CalOptima’s Claims Resubmission process prior to filing a complaint. If the provider is not satisfied with the payment decision, a complaint may be filed with CalOptima’s Grievance and Resolution Services Department.

Pharmacy: A provider shall first contact CalOptima’s Pharmacy Benefit Manager, PerformRX, in connection to the program to which the complaint pertains.

  • OneCare (HMO SNP) (Medicare Part D): 1-800-555-5690

  • Medi-Cal (California Medicaid): 1-800-555-5690

  • Healthy Families Program (Children Only): 1-800-555-5690

If the provider is not satisfied with the decision, the provider may contact CalOptima’s Pharmacy Management Department at 1-714-246-8471.

All Other Issues

Health Network: A provider must file a complaint with the member’s assigned network prior to filing a complaint with CalOptima. If not satisfied with the decision as indicated in the network’s decision letter, the provider may file a complaint with CalOptima’s Grievance and Resolution Services Department.

Long Term Care: A provider must first file an appeal with the Long Term Care Department for denials related to level of care, hospice or specialty bed issued by that department. For administrative denials (denials related to late submission) or if dissatisfied with an LTC appeal decision, a provider may file a complaint with CalOptima’s Grievance and Resolution Services Department.

CalOptima Direct: For denials related to decisions determined by the Care Coordination Prior Authorization Department, a provider must file a UM appeal of that decision with the Care Coordination Prior Authorization Department. If dissatisfied with the UM appeal decision, a provider may file a complaint with CalOptima’s Grievance and Resolution Services Department.

Pharmacy: A provider shall first contact CalOptima’s Pharmacy Benefit Manager, PerformRX, in connection to the program with which the complaint pertains.

  • OneCare (Medicare Part D): 1-800-555-5690

  • Medi-Cal (California Medicaid): 1-800-555-5690

  • Healthy Families (Children Only): 1-800-555-5690

If the provider is not satisfied with the decision, the provider may contact CalOptima’s Pharmacy Management Department at 1-714-246-8471.

Required Documentation for Review of a CalOptima Provider Complaint

To ensure timely review of your complaint, please submit the following documents as applicable with your complaint to CalOptima’s Grievance and Resolution Services Department.

Health Network or Health Network Provider

  • Copy of the health network’s complaint decision letter

  • Copy of provider’s complaint letter to the network

  • Explanation of Benefits / Remittance Advice (RA)

  • Health network’s response Appeal / Resubmission

  • Eligibility verification, if applicable (POS slip or AEVS confirmation number)

  • Supporting documentation (e.g., medical records, contract / policy language specific to issue)

  • Authorization number / referral issued by network, if prior authorization is required

  • 24-hr emergency service notification documentation

  • Copy of clean claim (HCFA 1500 form or UB92)

CalOptima Pharmacy Provider

  • Complaint letter describing provider’s position

  • Claim payment documentation (if applicable)

  • Prior Authorization form, if applicable

  • Audit findings letter, if applicable

  • Supporting documentation (e.g., medical records, contract / policy language specific to issue, etc.)

CalOptima Direct or Long Term Care Provider

  • Copy of the completed Claim Resubmission Form sent to CalOptima

  • CalOptima Remittance Advice (RA)

  • CalOptima Resubmission Decision letter

  • Copy of clean claim (HCFA 1500, UB92 or 25-1)

  • Eligibility verification, if applicable (POS slip or AEVS confirmation number)

  • Supporting documentation (e.g., medical records, contract / policy language specific to issue)

  • Completed CalOptima Provider Complaint Form or complaint letter describing Provider’s position

  • Provider UM Appeal Request letter (if applicable)

  • CalOptima UM Appeal decision letter

  • Copy of all previously submitted authorization requests

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