Provider Complaint Process

How to file a provider complaint or dispute

Medi-Cal, OneCare (HMO SNP) and OneCare Connect maintains a provider complaint process to review and resolve provider disputes for claims payment, as well as utilization management decisions and other non-payment related issues.

How it works

There are two levels in the provider complaint process:

Level 1 complaints involve disputes related to decisions or actions taken by a CalOptima health network, or a third-party administrator (TPA) disputes of utilization management decisions or claims payment decisions by CalOptima. Depending upon the situation, Level 1 complaints are filed with either the CalOptima health network, a third-party administrator (TPA) or with CalOptima directly.
Level 2 complaints are disputes of CalOptima health network or a third-party administrator (TPA) Level 1 decisions or disputes of Level 1 decisions issued by the Utilization Management or Claims departments.

The provider complaint process contains different procedures, depending upon whether the provider filing the complaint is a Medi-Cal, OneCare (HMO SNP) or OneCare Connect contracted provider or non-contracted provider.

To review the complete provider complaint process, see section R1 of the CalOptima Health Provider Manual.

Provider Dispute Resolution Request Form Use this form to submit a Level 1 complaint.

Provider Complaint Resolution Form — Level 2 Use this form to submit a Level 2 complaint.

Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Relations department at 714-246-8600 or email providerservices@caloptima.org
Provider Reference Contact List

Provider Directory

Find a Provider
CalOptima Health works with over 3,700 Orange County physicians, making it easy for our members to get the care they need.

Check here for our extensive list of providers, health networks, medical groups, hospitals and pharmacies.

Claims

About Claims and Eligibility
Verify member eligibility or submit a request for treatment authorization.

Provider Trainings

Trainings by Topic
View the latest model of care and other educational materials designed to help you and your staff provide care for CalOptima Health members.

Los materiales en esta página de Internet están en formato PDF y para poder verlos requiere el programa Adobe Reader. Para bajar el programa gratuitamente, oprima aquí.