Provider Dispute Resolution Processes

 

Definition of a Provider Dispute

A provider dispute is a written notice from the contracting provider to Serra Community Medical Clinic, Inc that:

• Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested
• Challenges a request for reimbursement for an overpayment of a claim
• Seeks resolution of a billing determination or other contractual dispute

Provider Dispute Timeframe

 

Effective January 1, 2004, Serra Community Medical Clinic, Inc will accept disputes from contracting providers if they are submitted within 365 days of receipt of Serra Community Medical Clinic, Inc’s decision (for example, denial or adjustment) except as described below. If the provider does not receive a decision from Serra Community Medical Clinic, Inc, the dispute must be submitted within 365 days after the time for contesting or denying the claim has expired.

If the provider’s Provider Services Agreement (PSA) provides for a dispute-filing deadline that is greater than 365 calendar days, this longer timeframe will continue to apply unless and until the contract is amended.

 

Submission of Provider Disputes

 

When submitting a provider dispute, a provider must use a Provider Dispute Resolution Request Form. If the dispute is for multiple, substantially similar claims, a Provider Dispute Resolution Request Spreadsheet must be submitted with the Provider Dispute Resolution Request Form.

 

The provider dispute must include the provider’s name, ID number, contact information including telephone number, and the same number assigned to the original claim. Additional information is required:

• If the dispute is regarding a claim or a request for reimbursement of an overpayment of a claim, the dispute must include a clear identification of the disputed item, the date of service, and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect
• If the dispute is not about a claim, a clear explanation of the issue and the basis of the provider’s position thereon

A provider dispute that is submitted on behalf of a member will be processed through the member appeal process provided the member has authorized the provider to appeal on behalf of the member. When a provider submits a dispute on behalf of a member, the provider is assisting the member with his or her member appeal.

 

If the provider dispute involves a member, the dispute must include the member’s name, ID number, and a clear explanation of the disputed item, including the date of service, and the provider’s position thereon.

 

All provider disputes and supporting information must be submitted to:

Line of Business	Address
Commercial HMO, AIM, Healthy Families, Senior HMO, Medi-Cal	Serra Community Medical Clinic, Inc 9375 San Fernando Rd Sun Valley, CA 91352

If the provider dispute does not include the required submission elements as outlined above, the dispute will be returned to the provider along with a written statement requesting the missing information necessary to resolve the dispute. The provider must resubmit the dispute along with the missing information within 30 business days from the receipt of the request for additional information.

 

Serra Community Medical Clinic, Inc will not request that providers resubmit claim information or supporting documentation that was previously submitted to Serra Community Medical Clinic, Inc as part of the claims adjudication process unless Serra Community Medical Clinic, Inc returned the information to the provider.

 

Serra Community Medical Clinic, Inc will not discriminate or retaliate against a provider due to a provider’s use of the provider dispute process.

 

Acknowledgement of Provider Disputes

 

Serra Community Medical Clinic, Inc will acknowledge receipt of each provider dispute, regardless of whether or not the dispute is complete, within 15 business days of receipt.

 

Resolution Timeframe

 

Serra Community Medical Clinic, Inc will resolve each provider dispute within 45 business days following receipt of the dispute, and will provide the provider with a written determination stating the reasons for determination.

 

Past Due Payments

 

If the provider dispute involves a claim and is determined to be in favor of the provider, Serra Community Medical Clinic, Inc will pay any outstanding money due, including any required interest or penalties, within five business days of the decision. Accrual of the interest and penalties will commence on the day following the date by which the claim should have been processed.

 

Dispute Resolution Costs

 

A provider dispute must be processed without charge to the provider; however, Serra Community Medical Clinic, Inc has no obligation to reimburse the provider for any costs incurred during the provider dispute process.

 

Provider Inquiry Requests

 

For routine claim follow-up please call the claims department at Serra Community Medical Clinic, Inc at (818) 504-4681.

 

Submission of Provider Inquiry Requests

 

All provider inquires and supporting information must be mailed to:

 

	Line of Business	Address
	Commercial HMO, AIM, Healthy Families, Senior HMO, Medi-Cal	Serra Community Medical Clinic, Inc 9375 San Fernando Rd Sun Valley, CA 91352