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CMS Provider Disputes

Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider disagrees with the amount paid, including issues related to bundling of services. To dispute a claim payment, submit a written request within 120 calendar days of the remittance notification date and include at a minimum:

  A statement indicating factual or legal basis for the dispute
  A copy of the original claim
  A copy of the remittance notice showing the claim payment
  Any additional information, clinical records, or documentaion to support the dispute
  Dispute Form

If you have additional questions relating to a dispute decision made, you may contact us at:

Phone: (800) 956-8000

Fax:     (866) 929-7165

Mail:    PDR Department PO Box 6902 Rancho Cucamonga, CA 91729-6902

If you do not agree with the dispute determination, you have the option to request a Health Plan dispute review. Please send all dispute requests in writing, accompanied by all documentation to support your position, directly to the Provider Appeals and Disputes team by using the HMO address/addresses listed below.

The request for Health Plan Dispute Review must be received within 120 calendar days from the determination date of the initial dispute.

Aetna Medicare Health Plan
Appeals & Grievance Unit
P.O. Box 14067
Lexington, KY 40512
Fax: 866-604-7092

Anthem Blue Cross
Grievances and Appeals
OH0205-A537 Mail Location
4361 Irwin Simpson Rd
Mason, OH 45040-9392

Blue Shield
Appeals & Grievance Unit
P.O. Box 272540
Chico, CA 95927-2540

United Healthcare
Provider Appeals
P.O. Box 6106
Cypress, CA 90630
Care 1st
Attn: PDR Department
P.O. Box 3829
Montebello, CA 90640

Easy Choice Health Plan, Inc
Appeals & Grievance Unit
P.O. Box 260519
Plano, TX 75026-0519

Health Net Medicare Programs
Provider Services Department
P.O. Box 10406
Van Nuys, CA 91410

United Healthcare
CMS Provider Disputes
PO Box 30997
Salt Lake City, UT 84130-0997
Humana, Inc.
Appeals & Grievance Unit
P.O. Box 14165
Lexington, KY 40512-4165
Fax: 800-949-2961

Appeals & Grievance Unit
P.O. Box 4319
Rancho Cucamonga, CA 91729-4319

SCAN Claims Department
Appeals & Grievance Unit
P.O. Box 22698
Long Beach, CA 90801-5616

NAMM California provides this information on behalf of our affiliated entity PrimeCare Medical Network, Inc. and as the Management Services Organization (“MSO”) for the following physician organizations listed below:

PrimeCare Medical Network, Inc.
     Primecare Medical Group of Chino Valley, Inc.
     PrimeCare of Citrus Valley, Inc.
     Coachella Valley Physicians
     PrimeCare of Corona, Inc.
     PrimeCare of Hemet, Inc.
     PrimeCare of Inland Valley, Inc.
     PrimeCare of Moreno Valley, Inc.
     PrimeCare of Redlands, Inc.
     PrimeCare of Riverside, Inc.
     PrimeCare of San Bernardino, Inc.
     PrimeCare of Sun City, Inc.
     PrimeCare of Temecula, Inc.

Mercy Physicians Medical Group, Inc.

Primary Care Associates Medical Group, Inc.

Valley Physicians Network, Inc.

Empire Physicians Medical Group, Inc.

Additional Links:
   Provider Dispute Resolution Information - AB1455
   Claims Administration Services


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