Provider Dispute Resolution Overview
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Governs Sharp Health Plan's procedures for receiving, validating, tracking, determining, appealing, and record-keeping of provider disputes (claims disputes) for applicable HMO/POS product lines in California.
No material clinical or coverage changes in this revision.
Validity and Eligibility Criteria
Validity criteria
Criteria for a valid Provider Dispute Resolution:
ALL of the following
ALL of the following
- Filed within 365 days of the plan's last action
ALL of the following
- Includes provider name and provider identification number
ALL of the following
- Includes provider contact information
ALL of the following
- Clear identification of the disputed item, date of service, and a clear explanation of the basis for the dispute (why the provider believes the payment amount, contest, denial, adjustment or other action is incorrect)
ALL of the following
- Date-stamp each dispute page upon receipt to record Date of Receipt
Claims Research stamps pages when PDR received
- After validation, log PDR into HealthRules the same day to assign an Issue/ tracking number
Issue creation date must equal receipt date
- Create ICE-approved PDR tracking form after assignment to monitor progress and turnaround
Filing Timeliness and Code Table
| No codes listed |
Submitting and Responding to Provider Disputes
Submit a written Provider Dispute Resolution (PDR)
Submit a written Provider Dispute Resolution (PDR) to challenge, appeal, or request reconsideration of a denied, adjusted, or contested claim, or to dispute a billing determination or request for overpayment reimbursement. The PDR must include provider name, provider identification number, provider contact information, clear identification of the disputed item, date of service, and an explanation of the basis for the dispute. File the PDR within 365 days of the plan's last action.
- Must be a written notice to the Plan challenging, appealing, or requesting reconsideration of a claim or billing/contract dispute.
- Include provider name and provider identification number.
- Include provider contact information.
- Clearly identify the disputed item, date of service, and the basis for the dispute.
- Filed less than 365 days from the Plan's last action.
Respond to a single request for additional information; amended PDR allowed
Respond to a single request for additional information if the Claims Research Specialist issues one; the Plan may request additional information only once per dispute. If the Plan requests missing information, you may submit an amended PDR within 30 working days of the Date of Receipt of the returned PDR.
- The Plan may issue one request for additional information per dispute.
- If information is missing, submit an amended provider dispute within 30 working days of the date of receipt of the returned provider dispute.
Key Terms and System Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.