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Provider Grievance Process

We understand the need for our provider partners to voice their concerns in a formal manner and receive a written response on the outcome. Providers may submit appeals on behalf of a member, however regulations require that written consent be obtained by the Provider prior to submission of an appeal on the member’s behalf. In accordance with the State and Federal appeal regulations for Medi-Cal, appeals filed by a provider on behalf of a member, must be accompany our Member Written Consent Appeal Form and return to CenCal Health.

Grievance Type
Time Limit
for Filing
Documentation to
Submit
How to Submit /
Who to Contact

Pre-service Appeals (All Auths)Member Billing Issues

Member/Member Representative or Provider on behalf of Member

Same as below for each grievance type Same as below for each grievance type CenCal Health                   Member Services Department
4050 Calle Real
Santa Barbara, CA 93110
1-877-814-1861
 Treatment Authorization Request (TAR) High Tech Imaging Requests Within 90 calendar days from the date of the original decision
  • Copy of original TAR and denial notification
  • Letter stating why denial or modification should be overturned
  • Documentation to support overturning the original denial or modification
CenCal Health
Health Services Department
4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1820
(805) 562-1019 (Medical Director)
Medical Request Form (MRF) Within 60 calendar days from the date of the original decision
  • Copy of original or modified MRF
  • Letter stating why denial or modification should be overturned
  • Documentation to support overturning the original denial or modification
  • A new completed MRF
CenCal Health
Pharmacy Services Department 4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1639
Claims Dispute Within 365 days of the date of the EOB on which the claim first appeared (non Medi-Cal programs) Within 6 months of the date of the EOB on which the claim first appeared (Medi-Cal programs)
  • Provider name & billing number
  • Member name & ID#
  • Date of Service (DOS)
  • Claim Control Number (CCN)
  • Clear identification of disputed item
  • Clear explanation of the basis for disputing payment amount, request for additional information, denial or adjustment
Submit the Claims Dispute/Appeal FormCenCal Health
Adjudication Department         4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1083