find

 View Primary Care Providers

or search below
find
find



about

 

EXTERNAL PROVIDERS

 

Claims

 
Submission & Inquiry   Payment & Processing   Dispute Resolution
 

Dispute Resolution Process for Contracted Providers
Definition of a Contracted Provider Dispute

 
A contracted provider dispute is a provider’s written notice to Facey Medical Foundation challenging, appealing, or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted, or contested or seeking resolution of a billing determination of other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered), or disputing a request for reimbursement of an overpayment of a claim.  Each contracted provider dispute must contain, at a minimum the following information:
 
  • Provider’s name
  • Provider’s identification number
  • Provider’s contact information
 
If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim, the following must be provided:
 
  • A clear identification of the disputed item, the date of services, and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment, or other action is incorrect;
  • If the contracted provider dispute is not about a claim, you must provide a clear explanation of the issue, and the provider’s position on such issue;
  • If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service and provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollee(s) must be provided.
 

Substantially similar multiple claims, billing, or contractual disputes may be filed in batches as a single dispute, provided that such disputes are submitted in the following format:

 
  • Sort provider dispute by similar issue.
  • Provide cover sheet for each batch.
  • Number each cover sheet.
  • Provide a cover letter for the entire submission describing each provider dispute with references to the numbered coversheets.
 

Mail Provider Disputes to:
Facey Medical Foundation
Claims Department
P.O. Box 9605
Mission Hills, CA 91346