Reconsiderations

Providers have the right to request the reconsideration of a claim determination. The reconsideration will be categorized as either an Appeal or Provider Dispute Resolution (PDR). Please carefully review the information on this page to submit your reconsideration request to the appropriate party with complete information.

Non-contracted providers may submit a reconsideration request to us only when the payment received is less than would have been received from Original Medicare. All other requests, including those for down coding, level of care, bundling, or denial should be submitted as an Appeal to the members health plan.

Contracted providers may submit a Provider Dispute Resolution request directly to us for review.

Appeal Submission

Non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination, in whole or in part, including issues related to bundling, level of care, or down coding of services/DRG. To appeal, submit a written request within 65 calendar days of the remittance notification date and include at a minimum:

A statement indicating factual or legal basis for appeal
A signed Waiver of Liability (WOL) form. You may obtain a copy by clicking here.
A copy of the original claim
A copy of the remittance notice showing the claim denial
Any additional information, clinical records, or documentation

Once the plan receives the completed Waiver of Liability form, and all other appropriate documentation, you will be given a decision on your appeal within 60 calendar days.
Mail the appeal request to the pertinent health plan address found below.

Astiva Health Plan: Astiva Health Plan, Appeals and Grievances, 765 The City Drive South, #200, Orange, CA 92868
Alignment Health Plan: Alignment Healthcare, Attn: Provider Appeals and Disputes, PO Box 14012, Orange, CA 92863
Brand New Day: Brand New Day, ATTN: Provider Dispute Resolution, P.O. Box 93122, Long Beach, Ca. 90809-3122
Clever Care Health Plan: Clever Care Health Plan, Attn: Provider Dispute Resolution Department, 7711 Center Avenue, Suite 100, Huntington Beach, CA 92647
Central Health Plan: Central Health Plan, ATTN: Appeals Department, P.O. Box 14244 Orange CA, 92863

Imperial Health Plan: Imperial Health Plan of California, P.O. Box 60874, Pasadena, CA 91116
Wellcare Health Plan:: Wellcare Health Plans, Inc. Attn: Appeals Department, P.O. Box 31368 Tampa, FL 33631-3368

Provider Dispute Resolution Submission

A payment dispute may be filed when the provider contends that the amount paid by the payer for a covered service is less than the amount that would have been paid under Original Medicare. To dispute a claim payment, submit a written request within 120 calendar days of the remittance notification date and include at a minimum:

A statement indicating factual or legal basis for the dispute
A copy of the original claim
A copy of the remittance notice showing the claim payment
Any additional information, clinical records, or documentation to support the dispute
A signed Waiver of Liability

Medical Group should be referenced in address line to facilitate sorting of Appeal / Dispute for prompt processing.

"Medical Group Name c/o Golden Coast MSO"

Attn: Disputes/Claims Department

PO BOX 1296

RIVERSIDE, CA 92502

Waiver of Liability