Medi-Cal and OneCare (HMO D-SNP) maintain a provider complaint process to review and resolve provider disputes regarding claims payment, utilization management decisions and other non-payment-related issues.
CalOptima Health uses a single internal review process for CalOptima Health Community Network disputes and those where CalOptima Health has financial responsibility for the claim. This process is handled through the Grievance and Appeals Resolution Services (GARS) department. This one-level internal review provides 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.
For disputes related to a CalOptima Health-contracted health network’s claim payment, a provider must submit the dispute through the appropriate health network for resolution. If the provider is not satisfied with the health network’s decision, 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 contracted through Medi-Cal or OneCare or is a non-contracted provider.
To review the complete provider complaint process, see section R1 of the CalOptima Health Provider Manual.
We have created two forms to distinguish the different types of requests and guide you through the process of submitting your request.