Provider Dispute Resolution (PDR) Mechanism

Whenever a provider claim is denied, contested or adjusted (claim not paid at 100% of billed charges), Western Health Advantage (WHA), or one of its Contracted Medical Groups/IPAs (CMGs), will inform the provider in writing of the availability of the provider dispute resolution (PDR) mechanism and the procedures for obtaining forms and instructions for filing a provider dispute. This process is available for use by both contracted and non-contracted providers who disagree with the plan's or CMG's decision.

Plan Level Disputes?

Provider disputes for denied, contested or adjusted claims issued by WHA should be filed with WHA and not with the CMG. For PDR inquiries or filing instructions, you can call WHA at (916) 563-2250 or (888) 563-2250 (toll free) or (888) 877-5378 (TTY/TDD).

Or you can mail a written request, along with your denial notice, a brief description of your issue and any other relevant information, to:

Western Health Advantage
Attn: Provider Dispute Resolution
2349 Gateway Oaks Drive, Suite 100
Sacramento, CA 95833

For your convenience, you can download and complete the attached standardized Provider Dispute Resolution Request form.

Provider disputes for claims must be received within 365 days from the most recent action on the issue. In cases of inaction, disputes must be received within 365 days after the time for contesting or denying the claim has expired. Disputes received after this deadline will be rejected and returned to the provider.

WHA will acknowledge a written dispute within 15 working days of receipt and make a final determination within 45 working days. If a dispute is returned for additional information, you have 30 working days to provide the information to WHA. If the information is received timely, the dispute will be processed within 45 working days from date of receipt of the additional information. If the additional information is not received or not received timely, the dispute will be closed.

Multiple claims that are substantially similar can be filed in batches as a single provider dispute in a bundled notice with individual claims numbered and identified by the original claim number. The attached Provider Dispute Resolution Request for Multiple "Like" Claims form is provided for your use.

If a dispute is submitted by a provider on behalf of an enrollee, it will be handled through WHA's grievance process, rather than the provider dispute process.

Contracted Medical Group/IPA (CMG) Level Disputes

Provider disputes involving denied, contested or adjusted claims issued by a CMG should be filed with the CMG rather than with WHA. Contact the CMG directly for information about their PDR process or for a copy of their Provider Dispute Resolution Request forms, or visit their website.

Provider disputes involving issues of medical necessity or utilization management can be appealed to WHA within 60 working days after issuance of final determination by the CMG.