Providers File a Grievance

Provider Grievance Process

We understand the need for our provider partners to voice their concerns in a formal manner and receive a written response on the outcome.

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