Corrections, Disputes & Appeals

Please submit corrections to previously billed claims by submitting a corrected claim utilizing one of the standard claim forms. These types of corrections may include a coding or modifier change, change to the billed charges or units, or submission of required documentation, but do not include a change to the date(s) of service.

For changes to the date(s) of service, please utilize the Date of Service Claim Correction Form.

Claims may also be corrected on CenCal Health’s website, but only prior to appearing on an EOP.

For frequently asked questions about submitting claim corrections, please access our Claim Corrections FAQ.

Disputes

CenCal Health makes available a dispute resolution process for all lines of business that may include contesting a payment amount or denial, or filing a complaint (any expression of dissatisfaction). Please use CenCal Health’s Provider Claim Dispute form for submitting claim disputes or complaints. 

For Medi-Cal: Disputes must be submitted within 6 months using the dispute form along with all supporting documentation explaining the reason for your dispute. 

For HF, HK, AIM (PP2 Product), IHSS. Disputes must be submitted within 365 day from the date of the action that lead to the dispute or the most recent action, if there were multiple actions. In the case of CenCal Health's inaction, contracted provider disputes must be received by CenCal Health within 365 days from the date the service was rendered to the CenCal Health member. If the member has other health coverage, claims must be received within 180 days from the date of the EOP from the other health carrier. The Member cannot be billed for services that were denied due to Provider not meeting these requirements.

IMPORTANT NOTE: The Provider Claim Dispute form cannot be used for submitting tracers or claim corrections. Please re-submit corrected claims on your standard claim form unless correcting the date of service. For corrections to the date of service, please use the Date of Service Claim Correction Form.

Provider Claims Dispute Form

Click here to access the Provider Claim Dispute form.  Complete the form, attach all pertinent documentation, and mail to:

CenCal Health
4050 Calle Real
Santa Barbara, CA 93110
Attention: Claims Department

Acknowledgement

CenCal Health will acknowledge each dispute within 15 days of receipt and render a decision within 45 days of receipt of the Dispute Form. 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

An Appeal is the final step in the administrative process and a method for our Providers to resolve problems related to their Medi-Cal claims. 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 in writing within 90 days of the action/inaction precipitating the appeal. Failure to submit an appeal 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.

Provider Claim Appeal Form

An appeal may be submitted using the CenCal Health Provider Claim Appeal form.   

Necessary documentation should be submitted with each appeal to assist our staff in performing a thorough review of each case. All supporting documentation must be legible.  Below are some examples of documentation that may be required. Copies are acceptable:

  • Claim, corrected if necessary
  • All related Explanation of Payment's (EOP’s) from CenCal Health
  • Explanation of Medicare Benefits (EOMB) or Medicare Remittance Notice (MRN)
  • Other Health Coverage (OHC) payment or denial notice
  • All dated correspondence and cop(ies) of dispute(s) previously sent to and from CenCal Health to document timely follow up
  • TAR, SAR, RAF or Radiology Benefit Manager authorization
  • Manufacturer’s invoice or catalog page
  • A report if claim is for a “by report” procedure
  • Completed Sterilization Consent Form (PM 330)

Click here to access the Provider Claim Appeal Form.  Complete the form, attach all pertinent documentation, and mail to:

CenCal Health
4050 Calle Real
Santa Barbara, CA 93110
Attention: Claims Department

Acknowledgement

CenCal Health will acknowledge each appeal within 15 days of receipt and render a decision within 45 days of receipt of the Appeal Form. If the appealed claim is approved for processing, it will be subject to benefit policy and routine edits and will appear on a future Explanation of Payments.

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