Grievance Type
|
Time Limit
for Filing
|
Documentation to
Submit
|
How to Submit /
Who to Contact
|
| Pre-service Appeals (All Auths)
Member Billing Issues
Member/Member Representative or Provider on behalf of Member
|
Same as below for each grievance type
|
Same as below for each grievance type
|
CenCal Health Member Services Department
4050 Calle Real
Santa Barbara, CA 93110
1-877-814-1861 |
| Treatment Authorization Request (TAR)
High Tech Imaging Requests
|
Within 90 calendar days from the date of the original decision
|
- Copy of original TAR and denial notification
- Letter stating why denial or modification should be overturned
- Documentation to support overturning the original denial or modification
|
CenCal Health
Health Services Department
4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1820
(805) 562-1019 (Medical Director)
|
| Medical Request Form (MRF)
|
Within 60 calendar days from the date of the original decision
|
- Copy of original or modified MRF
- Letter stating why denial or modification should be overturned
- Documentation to support overturning the original denial or modification
- A new completed MRF
|
CenCal Health
Pharmacy Services Department
4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1639
|
Claims Dispute
|
Within 365 days of the date of the EOB on which the claim first appeared (non Medi-Cal programs) Within 6 months of the date of the EOB on which the claim first appeared (Medi-Cal programs)
|
- Provider name & billing number
- Member name & ID#
- Date of Service (DOS)
- Claim Control Number (CCN)
- Clear identification of disputed item
- Clear explanation of the basis for disputing payment amount, request for additional information, denial or adjustment
|
Submit the Claims Dispute/Appeal Form
CenCal Health
Adjudication Department 4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1083
|