Provider Complaint Process

How to file a provider complaint or dispute

Medi-Cal, OneCare (HMO SNP) and OneCare Connect maintains a provider complaint process to review and resolve provider disputes for claims payment, as well as utilization management decisions and other non-payment related issues.

How it works

There are two levels in the provider complaint process:

  1. Level 1 complaints involve disputes related to decisions or actions taken by a CalOptima health network, or a third-party administrator (TPA) disputes of utilization management decisions or claims payment decisions by CalOptima. Depending upon the situation, Level 1 complaints are filed with either the CalOptima health network, a third-party administrator (TPA) or with CalOptima directly.
  2. Level 2 complaints are disputes of CalOptima health network or a third-party administrator (TPA) Level 1 decisions or disputes of Level 1 decisions issued by the Utilization Management or Claims departments.

The provider complaint process contains different procedures, depending upon whether the provider filing the complaint is a Medi-Cal, OneCare (HMO SNP) or OneCare Connect contracted provider or non-contracted provider.

To review the complete provider complaint process, see section R1 of the CalOptima Health Provider Manual.  

Provider Dispute Resolution Request Form  Use this form to submit a Level 1 complaint.

Provider Complaint Resolution Form — Level 2  Use this form to submit a Level 2 complaint.

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