Provider Dispute Resolution (PDR) Mechanism

Whenever Western Health Advantage, or one of its capitated medical groups or IPAs, denies, contests or adjusts a claim, both contracted and non-contracted providers are informed in writing of the availability of a provider dispute mechanism. This process is used when the provider disagrees with the decision. A brief description follows:

For PDR inquiries or filing instructions, you can call WHA at 916-563-2250 (local), 888- 563-2250 (toll free) or 888-877-5378 (TTY/TDD).

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

Western Health Advantage
Attn: Appeals/Grievance Unit
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 last date of action on the issue. In cases of inaction, disputes must be received within 365 days from the most recent Time for Contesting or Denying Claims 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.

Medical Group/IPA Level Disputes
Provider disputes involving denials or claim adjustments first issued by a medical group/IPA should not be filed with WHA. Rather, they should be filed with the medical group/IPA. For medical group/IPA Provider Dispute Resolution Request forms or for information about their PDR process, contact the medical group/IPA 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 medical group/IPA.