Provider Dispute Resolution Overview
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Governs Sharp Health Plan's procedures for processing provider claim disputes, appeals, recordkeeping, and related communications for providers across applicable product lines (HMO, PPO, POS). Affects providers contracting with Sharp Health Plan and internal claims, customer care, and network teams.
No material clinical or coverage changes in this revision.
Provider Dispute Resolution (PDR) Processing Criteria
PDR Processing Criteria
Covered when ALL of the following validation, acknowledgement, investigation, determination, reprocessing, and communication steps are met:
ALL of the following
ALL of the following
- PDR received less than 365 days from last plan action
ALL of the following
- Includes provider name and provider identification number
- Includes provider contact information
- Includes clear identification of disputed item, date of service, and explanation of basis for dispute
ALL of the following
ALL of the following
- Claims Research logs the validated PDR into Tapestry and assigns an electronic tracking (CRM) number; date stamp the received date in the SMARTFORM
Acknowledgement timeframe
- If received electronically: send acknowledgement via Auto-Reply within 2 working days
- If received written or by fax: send acknowledgement letter within 15 working days
ALL of the following
ALL of the following
- Claims Research Specialist must make and issue a written determination within 45 working days of receipt of the PDR or amended PDR, stating pertinent facts and explaining reasons
Determination outcomes
- If determination is in favor of the provider: send claim to Claims Processing for reprocessing via the CRM process; Claims Processing notifies Claims Research when adjusted claim is complete; mail written determination within 5 working days of check issuance; conduct a PDR Sweep for other possibly affected claims when overturned due to contract or utilization review; interest and penalty requirements per AB 3275 apply beginning 01/01/2026
- If determination is in favor of the Plan: issue determination letter to provider on the same day the PDR is closed
ALL of the following
- Plan may request additional information only once per dispute; request letters must specifically state the information needed and be attached to the PDR packet
Provider response
- Provider may submit an amended PDR within 30 working days of date of receipt of a returned provider dispute
- Failure to respond to the single request for additional information constitutes cause to determine the dispute in favor of the Plan
ALL of the following
- Claims Processing reprocesses the claim; Claims Research mails the written determination and attaches copy of determination and copy of check to the PDR packet within 5 working days of issuance of the check
- If refund is required but not received within 30 working days from the dispute request, close the dispute and continue the refund request per Claims Overpayments and Retractions policy
ALL of the following
- Attach acknowledgement, request-for-information, and determination letters (and check copy when applicable) to the existing PDR packet in OnBase/Tapestry
Timeliness and Coding Notes
| No codes listed |
How to Submit and Amend a Provider Dispute
Submitting a Provider Dispute (PDR) — required contents and timeliness
Submit a written Provider Dispute Resolution (PDR) that includes the provider's name, provider identification number, provider contact information, a clear identification of the disputed item, the date of service, and a clear explanation of the basis for the dispute. The PDR must be received by the Plan within 365 days of the last Plan action to be considered valid.
- Include provider name and provider identification number.
- Provide provider contact information.
- Identify the disputed item and date of service (DOS).
- Explain the basis upon which the provider believes the payment, denial, adjustment, or other action is incorrect.
- Submit within 365 days of the last Plan action.
Responding to a Request for Additional Information
The Plan may issue a single request for additional information if no determination can be made; the request must specifically state the information needed. The provider may submit an amended PDR with the missing information within 30 working days of the date of receipt of the returned dispute.
- The Plan may request additional information only once per dispute.
- Request letters must specifically address the information requested to make a determination.
- Provider may submit an amended PDR within 30 working days of the date of receipt of a returned provider dispute.
- Failure to respond to the single request allows the Plan to determine the dispute in its favor.
Key Terms and System References
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.