MEDI-CAL Provider Disputes

Provider Questions, Concerns and Disputes

Providers can communicate questions and concerns to the Care1st Provider Network Operations Department by telephone, e-mails, in writing, or in person. Many of these questions and concerns can be addressed very quickly by a Provider Network Administrator.

Providers who are submitting corrected claims requested by the Care1st Claims Department should submit the corrected claims directly to the claims department with a reference to the Remittance Advice notice received. Corrected claims should not be submitted to the Provider Dispute & Resolution Department unless a denial was received.

Providers who are submitting claims for retro review (review after the services have been provided) should submit these claims directly to the claims department and not to the Provider Dispute & Resolution Department. If the Claims Department has requested that you send medical records, please submit your request to the claims department and not to Provider Dispute & Resolution Department. If the Claims Department has sent you a denial letter please submit your request to the Provider Dispute & Resolution Department.

If a provider would like to appeal or dispute a claim payment it must be submitted in writing by mail or facsimile to the Care1st Health Plan Provider Dispute & Resolution (PDR) Department. If a provider attempts to file a dispute via telephone, Care1st will assist the provider to file the dispute in writing by physical or electronic means. The provider appeal and/or dispute process and the Provider Dispute Form that is available on this Website. All appeals and/or disputes are entered in the Provider Dispute Database to be investigated and a response will be provided in writing.

In order to facilitate and process a provider payment issue the following instructions and processes have been made available to providers by line of business.

Medi-Cal Provider Disputes Policy and Procedure:

Medi-Cal providers have 365 days from the Plan’s action or the Plan’s capitated provider's action or, in the case of inaction, to submit a written dispute to Care1st Health Plan's Provider Dispute & Resolution (PDR) Department. Disputes may pertain to such issues as the authorization or denial of a service or the processing, payment or nonpayment of a claim, capitation issues or other issues. All written formal disputes will be responded to in writing. Upon receipt of the written dispute specifying the issue of concern, it will be logged on the Provider Dispute & Resolution Database. An acknowledgement letter will be sent to the provider within 15 working days of receiving the paper dispute.

Any provider dispute submitted on behalf of a member will be handled through the Member grievance and/or appeal process.

Care1st Health Plan shall send a written closure letter with the resolution to the provider within 45 working days of receipt of the provider dispute. Care1st shall retain all documentation related to the peer review in accordance with Section 53310 of the California Code of Regulation. All files shall be maintained for up to ten years.

Medi-Cal First Level Appeal

A Provider may appeal the decision made at Care1st Health Plan. Care1st will refer clinical provider appeals and other appropriate cases for professional peer review. When the appeal is referred to professional peer review:

  1. All parties concerned shall be notified that a referral has been made to professional peer review and that a final determination may require up to 45 working days from the acknowledgement of the receipt of the dispute
  2. The professional peer review shall make its evaluation and submit its findings and recommendations to the Plan and the Provider within 45 working days after the receipt of the dispute and all background information is supplied
  3. Care1st, after taking into consideration the findings and recommendations of the professional peer review, shall send a written closing letter outlining its conclusions within 45 working days of receipt of the provider appeal. Language in the letter will include the next appeal steps the provider can take with the issue.

Care1st shall retain all documentation related to the peer review in accordance with section 53310 of the California Code of Regulation. All files shall be maintained for five years.

Medi-Cal Second Level Appeal

A Provider may, after completing a first level appeal, submit a second level appeal. A second level appeal must be filed within 180 calendar days of receipt of the Plan's written report of its conclusion. It can also be used when Care1st Health Plan has failed to act within the deadlines set forth above. In the case of Medi-Cal, a second level appeal for a dispute can be filed with L.A. Care or Care1st Health Plan. The Provider shall submit the following:
  1. A letter requesting a review of the first level appeal
  2. A copy of the letter sent to Care1st Health Plan requesting a first-level appeal
  3. A copy of the original documents submitted to Care1st Health Plan
  4. A copy of the first level appeal/denial response letter if the second level of appeal is based on a denial
  5. A copy of any other correspondence between Care1st and the Provider that documents timely submission and the validity of the appeal
  6. Care1st Health Plan or L.A. Care shall acknowledge the second level appeal request by a Provider within 15 working days of its receipt. If the appeal is sent to L.A. Care they shall send written notice to Care1st Health Plan of the appeal. Care1st Health Plan or L.A. Care shall review the written documents submitted in the Provider's appeal, may ask for additional information, and may hold an informal meeting with the involved parties. L.A. Care shall send a written report of its conclusions and reasons to the Provider and the Plan within 45 working days of receipt of the appeal from the Provider.