PROVIDER Claim Disputes- THE “APPEALS PROCESS”
A Provider/Practitioner grievance or complaint is described in Title 22, California Code of Regulations (CCR), as a written entry into the appeals process. Molina maintains two (2) types of appeals:
- Appeals regarding non-payment or processing of claims known as Provider Disputes
- Appeals regarding modifications or denial of a pre-service request are considered Member appeals
A Provider/Practitioner of medical services may submit to Molina an appeal concerning the modification or denial of a requested service or the payment processing or non-payment of a claim by the Plan. Molina will comply with the requirements specified in Section 56262, of Title 22 of the CCR, and Title 28, CCR, Section 1300.71.38.
A Provider Dispute is defined as a written notice prepared by a provider that:
- Challenges, appeals, or requests reconsideration of a claim that has been denied, adjusted, or contested
- Challenges MHC’s request for reimbursement for an overpayment of a claim that has been denied, adjusted, or contested
- Challenges MHC’s request for reimbursement for an overpayment of a claim
- Seeks resolution of a billing determination or other contractual dispute
For claims with dates of service in 2004 or after, all provider disputes require the submission of a Provider Dispute Resolution Request Form or a Letter of Explanation, which serves as a written first level appeal by the provider. For paper submission, MHC will acknowledge the receipt of the dispute within fifteen (15) working days and within two (2) working days for electronic submissions. If additional information is needed from the provider, MHC has forty-five (45) working days to request necessary additional information. Once notified in writing, the provider has thirty (30) working days to submit additional information or the claim dispute will be closed by MHC.
Providers may dispute by submitting and completing a Provider Dispute Resolution Request Form within three hundred sixty-five (365) days from the last date of action on the issue. A written dispute form must include the provider’s name, identification number, and contact information, date of service, claim number, explanation for the dispute and all required documentation or proof to support the dispute.
Disputes with incomplete information and missing required documentation will not be processed. Molina will provide a written response to the provider within 45 working days from the date of the dispute and allows two levels of dispute.
How to Submit Provider Disputes:
Method 1: Molina Provider Portal (most preferred method):
- Log onto Molina’s Provider Portal at: https://provider.molinahealthcare.com/
- Search and identify adjudicated claim and submit a dispute/appeal
- Complete required information on the portal and upload required documents or proof to support the dispute
Method 2: Fax to (562) 499-0633
Method 3: Mail to:
Molina Healthcare of California
Attn: Provider Dispute Resolution Unit
P.O. Box 22722
Long Beach, CA 90801