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