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 |
|
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 |
|
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) |
|
Submit the Claims Dispute/Appeal FormCenCal Health Adjudication Department 4050 Calle Real Santa Barbara, CA 93110 (805) 562-1083 |