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Provider Dispute Resolution for Medi-Cal

Information Last Updated: 10/19/2018

Policy Statement

Universal Care dba Brand New Day is committed as a company to adhering to State and Federal laws, regulations, and guidance from the Centers for Medicare and Medicaid Services (CMS), the California Department of Managed Health Care (DMHC), and the California Department of Health Care Services (DHCS) in order to provide excellent service and care while preventing and correcting any fraud, waste, or abuse. Universal Care dba Brand New Day additionally is dedicated to improving the quality of care for members by following guidance published by the National Committee for Quality Assurance (NCQA) and other accrediting bodies.

Universal Care dba Brand New Day maintains a fast, fair, cost effective Provider Dispute Resolution (PDR) process for contracting and non-contracting providers per Medicare guidelines of the Centers for Medicare and Medicaid Service (CMS). Providers wishing to file a dispute are not subject to discrimination or retaliation. In processing provider disputes, Universal Care dba Brand New Day does not charge the provider for costs incurred and does not reimburse for expenses incurred by the disputing provider. All provider disputes must be received in writing and must be filed timely per Medicare guidelines.

Purpose

This policy to outlines the process for resolving Provider Disputes from contracted and non-contracted providers.

Scope

This policy applies to Provider Disputes for Medi-CAL

Definitions

Delegation
A formal process by which an organization gives another entity the authority to perform certain functions on its behalf. Although an organization may delegate the authority to perform a function, it may not delegate the responsibility for ensuring that the function is performed appropriately.
Non-Delegation
The process by which the organization does not contract with or otherwise arrange for another entity to perform functions and to assume responsibilities on their behalf.
Contracted Provider Dispute
Contracted provider means a contracted provider’s written notice to the plan or the plan’s capitated provider 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 or other contract dispute (or a 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.
Non-Contracted Provider Dispute
Non-Contracted Provider Dispute means a non-contracted provider’s written notice to the plan or the plan’s capitated provider challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim that contains.
PDR - Provider Dispute Resolution
DOS - Date of Service
EDI - Electronic Data Information

Procedure

  1. Submission, Receipt, Processing and Resolution Must:

    1. Provide the claim dispute be submitted using the original claim number
    2. Be processed and tracked in a manner allowing linkage with the original claim number
    3. Inform the provider of the availability of the PDR mechanism whenever contesting, adjusting or denying a claim, and the procedures for obtaining forms and instructions for filing a dispute including the mailing address.
  2. Disputes Regarding a Claim, or a Request for Overpayment Return Must:

    1. Clearly identify the disputed item
    2. Include the date of service (DOS)
    3. Provide clear explanation of the basis for the provider's reasons that the payment, request for overpayment return, request for additional information, contest, denial or adjustment is incorrect
    4. Includ disputing provider's name, identification number and contact information.
  3. For Contract Providers Only, If Dispute is Not Regarding a Claim or Request for Overpayment Return (i.e. a Contractual Issue) It Must Include:

    1. Clear explanation of the issue
    2. Provider's position thereon
  4. If Dispute is Submitted on Behalf of the Enrollee(s), Universal Care DBA Brand New Day Will Forward the Member Grievance to the Corresponding Health Plan Within 3 Business Days; Unless Delegated, Universal Care DBA Brand New Day Will Follow Pursuant to California Law and Regulations. It Must Include:

    1. The name and identification number of the enrollee(s)
    2. A clear explanation of the disputed item(s)
    3. The DOS
    4. The provider's position thereon
  5. Universal Care DBA Brand New Day Verifies the Enrollee(s) Authorization to Proceed with the Grievance Prior to Submitting Through the Member Grievance Process.

    1. When a dispute is submitted on behalf of the enrollee(s), the provider is deemed to be joining with or assisting the enrollee(s) with the meaning of Health and Safety Code Section 1368.
  6. Provide Dispute Deadlines for Submission:

    1. A deadline is imposed for receipt of provider disputes. The deadline is 90 calendar days from the last date of action on the issue, or in the case of inaction, will not be less than 90 calendar days from the most recent time for contesting or denying claims has expired.
    2. If not received by the defined deadline, the dispute will be upheld and an untimely filing closure letter will be mailed to the provider.
  7. Acknowledgement of Provider Disputes:

    1. Provider Disputes are acknowledged in writing within 15 working days of receipt for paper claim disputes and 2 working days for EDI claim disputes.
  8. Dispute Resolution Time Frames:

    1. Incomplete Provider Disputes:
      1. Will be returned to the provider for more information within 45 working days of receipt.
      2. Will clearly identify missing information needed to resolve the dispute.
      3. Cannot ask for claim documentation already submitted (unless returned to the Provider)
      4. Provider has 30 working days to submit additional information requested.
      5. If additional information is received timely, Universal Care dba Brand New Day will process as a completed provider dispute within 45 working days
      6. If additional information is not received or not received timely, the provider dispute will be closed.
    2. Completed Provider Disputes:
      1. Universal Care dba Brand New Day will make written determination of the dispute within 45 working days
      2. Determination will state pertinent facts.
      3. Determination statement will provide explanations for the decision.
  9. Disputes Decided in Whole or Part on Behalf of the Provider:

    1. Payment, including any applicable interest/penalties due will be made within 5 working days of the determination. The resolution letter will be printed and mailed 3 days prior to the date of payment and/or on the date of payment.
  10. Good Will Payments

    1. Payment, including any applicable interest/penalties due will not be made to "Good Will" payments as "Good Will" payments are based on project status of claims.
  11. Provider Right of Appeal:

    1. If the provider dispute involves an issue of medical necessity or utilization management (UM, the provider has an unconditional right to appeal the determination to the corresponding Health Plan within 60 working days from Universal Care dba Brand New Day's Date of Determination.
  12. Interest:

    1. Interest and penalties are applied on completed PDRs after 45 working days from the date of receipt of a COMPLETE claim. (If the original claim was received complete/clean, interest will be applied from the original receipt date of the first submission.)
    2. Interest and penalties will not apply to "Good Will" payments.
  13. Retention of Records:

    1. Copies of all PDRs and determinations, including all notes will be kept for a period of less than 5 years, the last 2 years of which will be maintained in an easily accessible place. After such records have been preserved for 2 years, they may be a warehoused or stored, microfilmed or scanned, subject to their availability to the Management within not more than 5 days after a request thereof.

Reporting

  1. Universal Care dba Brand New Day will provide a quarterly report to the contracted Health Plan's within 30 days following the close of each calendar quarter to include:

    1. Tabulated record of all disputes received.
      1. Categorized by:
        1. Date of receipt
        2. Identification of provider
        3. Type of dispute
        4. Disposition of dispute
        5. Working days to disposition
        6. Signed by the Principal Officer, with written verification stating the report is true and correct to the best of their knowledge and belief.

Provider Dispute Resolution for Medi-Cal

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