Resources

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:

  1. 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.
  2. 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 Provider Manual.  

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

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

Contact Us
Provider Directory
  • Find a Provider
    CalOptima 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
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 members.

Download the free Adobe Reader.

Materials available on this Website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe Website, click here.