Corrections, Disputes, & Appeals
To ensure provider corrections, disputes, and appeals are resolved efficiently and accurately, please avoid submitting duplicate requests for the same issue before receiving a response to your initial submission. Duplicate submissions may delay processing.
You can check the status of a corrected claim, dispute, or appeal by contacting our Claims Customer Service team Monday through Friday, 8 a.m. to 5 p.m.
- 805-562-1083 or
- 800-421-2560, ext. 1083
- Select Option 1 for CenCal Health or Option 2 for CenCal CareConnect
Please allow at least 15 days from the date of submission for initial processing. We appreciate your cooperation and partnership in helping us process all correspondence in a timely manner.
Please select either “Medi-Cal” or “CenCal CareConnect” below to ensure your request is routed correctly.
Claim Corrections
If a claim was previously denied due to missing or incorrect information, the quickest way to resolve it is to correct the information and resubmit the claim using the original submission method.
Contracted providers may also make corrections directly through our web portal before the claim is finalized or appears on an Explanation of Payment (EOP).
To submit a correction for a previously submitted claim, complete the Claims Correction Form. Please follow the form instructions included, then mail completed forms to:
Attn: Claims Mailroom
4050 Calle Real
Santa Barbara, CA 93110
Disputes
The first-level dispute is a Provider Dispute. A dispute may be submitted to contest the processing, payment, or nonpayment of a claim. CenCal Health reviews all inquiries, disputes, and written statements of contested claims or provider dissatisfaction to determine if the request meets criteria for processing as a dispute.
Disputes must be submitted using the CenCal Health Provider Dispute Form. Please note: if the dispute form is incomplete or missing required information, it will be returned for correction.
Disputes must be submitted within 6 months of the EOP date on which the claim first appeared. CenCal Health will acknowledge disputes within 15 business days of receipt and will send a written resolution of the dispute within 45 business days of the date we receive the request. If the disputed claim is approved for processing, it will be subject to benefit policy and routine edits and will appear on a future Explanation of Payment.
Appeals
If a provider is dissatisfied with the outcome of the dispute, they can submit a second-level dispute, known as an appeal. An appeal should be submitted only after a dispute has been submitted, and the outcome of the dispute does not meet the provider’s satisfaction.
Providers must submit the appeal using the CenCal Health Provider Appeal Form within 90 days of the action/inaction precipitating the complaint. Failure to submit within this 90-day period will result in the appeal being denied. CenCal Health reviews each case individually using the documents presented by the provider in order to render a fair decision.
Necessary documentation should be submitted with each appeal to assist our staff in performing a thorough review of each case.
Choose Contracted or Non-contracted to view the correct forms.
Contracted Providers
Claim Corrections
If a claim was previously denied due to missing or incorrect information, the quickest way to resolve it is to correct the information and resubmit the claim using the original submission method.
Contracted providers may also make corrections directly through our web portal before the claim is finalized or appears on an Explanation of Payment (EOP).
To submit a correction for a previously submitted claim, complete the Claims Correction Form. Please follow the form instructions included, then mail completed forms to:
Attn: Claims Mailroom
4050 Calle Real
Santa Barbara, CA 93110
Disputes
The first-level dispute is a Provider Dispute. A dispute may be submitted to contest the processing, payment, or nonpayment of a claim. CenCal Health reviews all inquiries, disputes, and written statements of contested claims or provider dissatisfaction to determine if the request meets criteria for processing as a dispute.
Disputes must be submitted using the CenCal Health Provider Dispute Form. Please note: if the dispute form is incomplete or missing required information, it will be returned for correction.
Disputes must be submitted within 6 months of the EOP date on which the claim first appeared. CenCal Health will acknowledge disputes within 15 business days of receipt and will send a written resolution of the dispute within 45 business days of the date we receive the request. If the disputed claim is approved for processing, it will be subject to benefit policy and routine edits and will appear on a future Explanation of Payment.
Appeals
If a provider is dissatisfied with the outcome of the dispute, they can submit a second-level dispute, known as an appeal. An appeal should be submitted only after a dispute has been submitted, and the outcome of the dispute does not meet the provider’s satisfaction.
Providers must submit the appeal using the CenCal Health Provider Appeal Form within 90 days of the action/inaction precipitating the complaint. Failure to submit within this 90-day period will result in the appeal being denied. CenCal Health reviews each case individually using the documents presented by the provider in order to render a fair decision.
Necessary documentation should be submitted with each appeal to assist our staff in performing a thorough review of each case.
Non-contracted Providers
Claim Corrections
If a claim was previously denied due to missing or incorrect information, the quickest way to resolve it is to correct the information and resubmit the claim using the original submission method.
To submit a correction for a previously submitted claim, complete the Claim Correction Form. Please follow the form instructions included.
Dispute – Provider may only dispute full approvals
A dispute may be submitted to contest the payment of a claim. CenCal CareConnect reviews all inquiries, disputes, and written statements of contested claims or provider dissatisfaction to determine if the request meets criteria for processing as a dispute.
Disputes must be submitted using the CenCal CareConnect Provider Dispute Form. Please note that if the dispute form is incomplete and does not include the required information, we will return the request to you for more information.
Disputes must be submitted 65 days from the EOP date on which the claim first appeared. CenCal CareConnect will acknowledge disputes within 15 business days of receipt and will send a written resolution of the dispute within 60 days of the date we receive the request. If the disputed claim is approved for processing, it will be subject to benefit policy and routine edits and will appear on a future Explanation of Payment.
Appeals – Providers may only appeal full or partial denials
CenCal CareConnect non-contracted appeals must be submitted within 65 calendar days from the date of notification (Remittance Advice) of CenCal CareConnect claim action. Providers must sign and submit a Waiver of Liability verifying that they relinquish the right to collect payment from the member in order for CenCal CareConnect to process the appeal.
Non-contracted providers who want to submit an appeal of a denied claim must submit the appeal and a Waiver of Liability Form to the Claims Department.
The following are examples of appeals:
- Benefit/Frequency Limits Exhausted
- Medical Necessity
- Eligibility
- Non-covered Service
- Erroneous denial reason
- Bundled Codes
CenCal CareConnect Provider Waiver of Liability Form
If a waiver is not submitted, CenCal CareConnect will make reasonable efforts to obtain the Waiver of Liability by making two attempts. A request for the waiver will be sent when the appeal is received and again after 15 calendar days have passed. If the waiver is not received within 60 days after the receipt of the appeal request, the request will be dismissed, and a formal notice of dismissal will be sent to the provider, indicating the reason for the dismissal and the next steps available to the provider.