Provider Complaint Process

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.

Effective 1/1/24, CalOptima Health transitioned to a single internal review process for CalOptima Health Community Network disputes and those where CalOptima Health has the financial responsibility for the claim. This process will be handled through the Grievance and Appeals Resolution Services (GARS) department. The one level internal review streamlines the process by providing a fast, fair, and cost-effective dispute resolution mechanism to process and resolve contracted and non-contracted provider disputes and reduces the timeframe for the provider to receive a final decision by CalOptima Health.

This change does not impact CalOptima Health’s contracted Heath Networks’ claims payment or provider dispute rights and/or processes with CalOptima Health’s contracted Health Networks. For disputes related to a CalOptima Health’s contracted health network’s claim payment, a provider shall submit the dispute through the appropriate health network for resolution. If the provider is not satisfied with the decision by the health network, the provider may submit a request for a second level review by CalOptima Health’s GARS department.

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.  

To guide you on the process and where to submit your request, we have created two new forms to distinguish the different types of requests.

Provider Claims Dispute Form   

Provider Service Authorization Dispute Request