New Provider Dispute Resolution (PDR) Legislation

New legislation effective January 1, 2004 (AB 1455) established a fast and fair process for resolving provider disputes within prescribed timeframes. Whenever the health plan or its capitated IPA/group contests, adjusts or denies a claim, both contracted and non-contracted providers will be notified of the availability of the PDR mechanism and procedures for obtaining forms and instructions, including the mailing address, for filing a provider dispute (appeal).

IPA/Group Level Dispute
If a dispute involves a denial or claim adjustment that was first issued by an IPA or medical group, the provider should file a dispute with that IPA or group and not with the plan. If the dispute involves medical necessity or a utilization management issue, providers will have the unconditional right to file a dispute at the plan level within 60 working days after issuance of a final determination by the IPA/group. This means that providers will have a second level reconsideration review mechanism available in some cases if they are dissatisfied with the initial dispute decision made by the IPA/group. For IPA/group Provider Dispute Resolution Request forms and additional information about the PDR process, contact your IPA/group or check their website.

Plan Level Dispute
A provider may file a dispute at the plan level for two reasons: 1) when a provider receives an initial denial or claim adjustment from someone at the plan level; or 2) when a provider is dissatisfied with the IPA/group's dispute outcome and the case involves medical necessity or a UM decision. To file a dispute with WHA, download and complete the Provider Dispute Resolution Request form below. Receipt of the completed form will be acknowledged within prescribed timeframes and WHA's appeal staff will process the request and notify the provider of the outcome in writing in a timely manner.