CCHP has a Provider Dispute Resolution (PDR) process that ensures provider disputes are handled in a fast, fair and cost effective manner.

A provider dispute is a written notice from a provider that:

• Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested, or
• Challenges a request for reimbursement for an overpayment of a claim, or
• Seeks resolution of a billing determination or other contractual dispute.

How to Submit Provider Disputes

Providers must use a Provider Dispute Resolution Request Form (PDF)*.

You may download Instructions for Submitting Provider Disputes (PDF)* or call CCHP Provider Relations at 415-955-8800, ext. 3214 for assistance.

Disputes can be mailed to:

Chinese Community Health Plan
Attention: Provider Dispute Resolution Area
445 Grant Avenue, Suite 700
San Francisco, CA 94108

Disputes can be faxed to: 1-415-955-8815

Resolution Timeframe

CCHP will resolve each provider dispute within 45 business days following receipt of the dispute, and will provide the provider with a written determination stating the reasons for the determination.

Non-Contracted Provider Dispute Resolution Process For CMS Medicare Advantage Plan Members

Effective January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) expanded its independent review provider payment dispute resolution process to include disputes between non-contracted Medicare Advantage HMO providers. Medicare Advantage plans implemented this regulation effective January 2011. CCHP has two Medicare Advantage plans: CCHP Senior Program (HMO) and CCHP Senior Select Program (HMO SNP).

Independent review by CMS is available after you have completed CCHP's first level dispute process.

Download details of the CMS Non-Contracted Provider Dispute Process here.