PROVIDER DISPUTES

A provider dispute is a written notice from a provider that challenges, appeals, or requests consideration in any of the following categories:

  • Claim
  • Billing Determination
  • Appeal of Medical Necessity
  • Utilization Management Decision
  • Request for Reimbursement of Overpayment
  • Contract Dispute
  • Other Categories Not Listed

HOW TO SUBMIT PROVIDER DISPUTES
Providers are required to complete the necessary PDR forms:
Provider Dispute Resolution Request Form
Provider Dispute Resolution Request Information Supplement

Disputes must include:

  • Provider's Name/ ID Number
  • Contact information including phone number
  • The number assigned to the original claim (on the EOB)

DISPUTE SUBMISSION
Completed dispute forms must be mailed to:

EXCEL MSO, LLC
AAMG/CCHCA Provider Appeals
P.O. Box 1120
San Jose, CA 95108

Unless required by any state or federal law or regulation, provider disputes must be received within 365 days from denial or payment determination or in the case of inaction, within 365 days of the time for contesting or denying claims.