Claims Submissions

The California Department of Managed Health Care (DMHC) set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the DMHC.  These regulations comply with Assembly Bill 1455 (AB1455). This notice informs you of your rights, responsibilities, and procedures for claim settlement and dispute submission for the Alliance Medi-Cal, Healthy Families, Alliance Group Care and Alliance CompleteCare members. Unless otherwise provided herein, capitalized terms have the same meaning as set forth in Sections 1300.71 and 1300.71.38 of Title 28 of the California Code of Regulations.

For more information on AB 1455, go to the DMHC website.

This page includes the following information for providers on the following topics:

I.     Claim Submission Instructions
II.    Dispute Resolution Process for Contracted Providers
III.   Dispute Resolution Process for Non-Contracted Providers
IV.   Provider Dispute Resolution Submission Form
V.    Claim Overpayments

Providers with questions regarding this information should contact the Alliance Claims Department at (510)747-4530 Monday through Friday, between 8:00 a.m.-5:00 p.m.

I. Claim Submission Instructions

A. Submitting Claims to the Alliance

Providers should review the Alliance member ID card for the claims billing address.

If sending claims by US Postal Service:

  • Professional Claims for all Alliance members should be submitted for processing as follows:
    • If the member/patient is assigned to an Alliance Primary Care Physician, submit claims to:
      Alameda Alliance for Health
      P.O. Box 2460
      Alameda, CA 94501-0460
    • If the member/patient is assigned to a Children's First Medical Group (CFMG) Primary Care Physician, submit claims to:
      Children's First Medical Group
      P.O. Box 3359
      Oakland, CA 94609
    • If the member/patient is assigned to a Community Health Center Network (CHCN) Primary Care Physician, submit claims to:
      Community Health Center Network
      101 Callan Ave, Suite 300
      San Leandro, CA 94577
  • Hospital/Facility claims for all Alliance members should be submitted for processing to:
    Alameda Alliance for Health
    P.O. Box 2460
    Alameda, CA 94501-0460
  • Mental Health claims for Alliance Medi-Cal members should be submitted for processing to:
    Alameda County Behavioral Health Care Services
    Claims Processing Department
    P.O Box 738
    San Leandro, CA 94577
  • Mental Health claims for Alliance Healthy Families and Alliance Group Care (as of January 1, 2014) should be submitted for processing to:
    Beacon Health Strategies/CHIPA Mental Health & Substance Abuse Services
    5665 Plaza Drive, Suite 400
    Cypress, CA 90630
  • Mental Health claims, as of August 1, 2013, for Alliance CompleteCare members should be submitted for processing to:
    Beacon Health Strategies/CHIPA Mental Health & Substance Abuse Services
    5665 Plaza Drive, Suite 400
    Cypress, CA 90630
  • Vision Care claims for Alliance Medi-Cal members should be submitted for processing to:
    March Vision Care
    6701 Center Drive West Suite 790
    Los Angeles, CA 90045

If submitting claims via Electronic Data Interchange (EDI):

  • Providers interested in submitting claims electronically should contact Alliance Claims Customer Service at (510) 747-4530 for information and submission requirements.
  • Claims that require attachments, invoices, etc. may not be sent electronically. They must be submitted on the appropriate paper claim form with the attachments.

B. Reaching the Alliance for Claims

Immediate response related to claims or check status can be obtained by Alliance Contracted providers using the Alliance iDiamond Online Provider Connection. Contact your Alliance Provider Representative or the Alliance Provider Relations Department at (510) 747-4510 for information on how to obtain an iDiamond account.

For additional claim submission requirements or more complex claim inquiries, contact the Alliance Claims Department at (510) 747-4530, Monday through Friday, between 8:30 a.m.–4:00 p.m. When requesting the status of a claim, you must identify yourself and provide the following information:

  • Patient Name
  • Insured's Identification Number
  • Provider's Name
  • Date of Birth of Patient
  • Date of Service of the Claim
  • Billed Charges
  • Provider's Tax Identification Number

If a caller requests the status of a claim and cannot provide the seven elements listed above, claim information will not be released. Once the identity of the caller has been established, protected health information (PHI) can be discussed as needed to resolve the phone call.

C. Claim Receipt Verification

Verification of claim receipt can be obtained by calling the Alliance Claims Customer Service at (510) 747-4530, between 8:30 a.m.-4:00 p.m. The Alliance will acknowledge receipt of paper claims within 15 working days. Claims received electronically will be acknowledged within two working days.

D. Claim Submission Requirements

Timeframe for Claim Submission:
  • Claims must be submitted timely:
    • Participating (contracted) providers must submit clean claims within 180 calendar days post service, or post date from Explanation of Benefits (EOB), if other coverage exists.
    • Non-Participating (non-contracted) providers must submit clean claims within 365 calendar days post-service, or post date from Explanation of Benefits (EOB), if other coverage exists. 
    • Corrected claim previously denied by the Alliance as an incomplete claim: The claim must be submitted correctly for reconsideration of payment within 180 days of the date of the original denial by the Alliance. A corrected claim may be mistaken as a duplicate claim submission unless it is clearly identified as such.
Submitting Claims Outside of the Filing Period:

If a claim is submitted outside of the timeframes stated above, proper documentation, also known as “proof of timely filing”, must be attached to the late claim.

Acceptable proof of timely filing includes:

  • Certified mail receipt proving claims were received by the Alliance.
  • Copy of the Remittance Advice or EOB from the primary payer indicating the date of resolution (payment, date of contest, denial, or notice) if the claim was denied for untimely EOB.
  • Copy of the Alliance EDI Preprocessing Acceptance or Error Report for claims originally submitted electronically.
  • Copy of the Alliance's Remittance Advice (RA) indicating the date and reason for the original denial for unclean claim denials.
  • Documentation/Explanation of the cause for the delay in submitting a claim to the Alliance when the provider experiences exceptional circumstances beyond his/her control.
Claim Processing Time

The Alliance will process and pay all clean claims within 45 working days from receipt. Alliance CompleteCare claims will process and pay within 30 calendar days from receipt.

Clean Claim

A clean claim is defined as a claim which, when it is originally submitted, contains all necessary information, attachments, and supplemental information or documentation needed to determine payer liability, and make timely payment.

Interest on Claims

The Alliance will calculate and automatically pay interest, in accordance with AB1455 and prompt payment requirements, to all providers of service who have not been reimbursed for payment, within 45 working days from the receipt of their clean claim. The Alliance will automatically pay interest for clean Complete Care claims not paid within 30 calendar days from receipt.

Misdirected Claims

When a claim is incorrectly sent to the Alliance that should have been sent to one of its delegated partners (i.e., Community Health Center Network, Beacon Health Strategies/CHIPA Mental Health & Substance Abuse Services, etc.), the Alliance will forward the claim to the appropriate delegated partner within ten working days from receipt of the claim. The provider will also receive a notice of denial with instructions to bill the delegated entity.

Claims Coding

The Alliance has a responsibility to control healthcare costs for our providers and for all members. Claims coding and editing enables us to more effectively and universally implement fair reimbursement rules and guidelines aimed at preventing fraud and providing equitable reimbursement to all providers.

  • Alliance follows National Correct Coding Initiatives (NCCI) for coding purposes unless otherwise indicated.
  • Anesthesia services are to be reported by use of the Level I CPT 5-digit anesthesia procedure code (00100-01999), plus modifier codes as defined in the Anesthesia Guidelines of the AMA Current Procedural Terminology.
  • Alliance updates all systems both annually and quarterly for new codes. New codes will be effective and accepted by Alliance January 1 of each year, following announcement of the new code.
  • Covered Level II HCPCS Temporary Codes will be reimbursed at a percent of billed charges.
Claim Form Requirements

The Alliance has established requirements for filing a claim for payment consideration. Failure to comply with these requirements may jeopardize the claim for reimbursement. To be accepted as a valid claim, the submission must meet the following criteria:

  • Must be submitted on a standard current version of a CMS 1500, CMS-1450 or the ANSI X12-837-4010A1 or most current electronic format.
  • Must contain appropriate information in all required fields.
  • Must be a claim for an Alliance member eligible at the time of service. (Always verify eligibility via the iDiamond or calling Member Services)
  • Must contain correct current national standard coding, including but not limited to CPT, HCPCS, Revenue, NDC, and ICD-9 codes.
  • Must not be altered by handwritten additions to procedure codes and/or charges.
  • Must be signed, if paper.
  • Must be printed with dark ink that is heavy enough to be electronically imaged, if submitted as a paper claim.
  • Level III HCPCS (Local Codes) will be accepted in accordance with the DHCS’ transition plan to Level II HCPCS and CPT Coding.
  • California regulations require that claims for sterilization services for Medi-Cal members, including services for tubal sterilization, vasectomy, and hysterectomy, must be accompanied by the PM330, signed by the member a minimum of 30 days prior to the date of surgery. Consequently, the Alliance will not reimburse professional or facility fees associated with sterilization services unless an appropriately completed consent form is submitted by the primary surgeon. Claims submitted without this form will be denied for payment.
  • Medi-Cal Child Health and Disability Prevention (CHDP) Program providers must submit the PM160 for all CHDP preventive services for Alliance Medi-Cal members between 0-21 years of age along with the CMS 1500 form.
  • Claims billed for office injectibles must include properly formatted NDC code and units of measure. See examples of paper claim submission below. Office injectible codes billed without NDC, unit of measure or in an incorrect format will be denied. Please see Medi-Cal website for additional details.

NDCs and units billed on CMS1500:
CMS 1500

NDCs and units billed on CMS1450:
CMS1450

Additional Information
  • All disposable and incontinence supplies must be billed with the UPN in addition to the HCPCS Level II code. For EDI claims, impacted medical supply products must be billed with HCPCS Level II codes using the ASC X12N 837P 4010A1 format. See example of paper claim submission below. Claims billed without the Universal Product Number (UPN) or medical supply claims which are not submitted in the required format will be denied. See Medi-Cal website for additional details.
    Claim submission
  • Laboratory/Pathology Services: Except for Emergency and Urgent Care Services, and those lab services identified as covered under Primary Care Physician Capitation or specifically identified as reimbursed fee-for-service, laboratory services are carved out to the Health Plan's capitated laboratory provider, Quest Diagnostics. Pathology services, identified as CPT-4 procedure Code range 88300-88399, are payable by the Health Plan only when performed in conjunction with emergency or urgent care services, or surgical services performed in an inpatient hospital, outpatient hospital, or free standing surgical facility setting.

II. Dispute Resolution Process for Contracted Providers

A. Definition of Contracted Provider Dispute

A contracted provider dispute is a provider's written notice to the Alliance challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered) or disputing a request for reimbursement of an overpayment of a claim. Each contracted provider dispute must contain, at a minimum the following information: provider's name; provider's identification number, provider's contact information, and:

i. If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from the Alliance to a contracted provider the following must be provided: a clear identification of the disputed item, the date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect;

ii. If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider's position on such issue; and

iii. If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service and provider's position on the dispute, and an enrollee's written authorization for provider to represent said enrollees.

B. Sending a Contracted Provider Dispute to the Alliance

Contracted provider disputes submitted to the Alliance must include the information listed in Section II.A., above, for each contracted provider dispute. All contracted provider disputes must be sent to the attention of the Claims Department as listed below:



Claims Disputes

Authorization Disputes

NOPD Unit - Claims Department

Alameda Alliance for Health

P.O. Box 2460

Alameda, CA 94501-4506

(Fax) 877-747-4506

 



C. Time Period for Submission of Provider Disputes

Contracted provider disputes must be received by the Alliance within 365 days after the last date of action that led to the dispute, or in the case of inaction, contracted provider disputes must be received within 365 days after the provider's time for contesting or denying the claim has expired.

Contracted provider disputes that do not include all required information as set forth above in Section II.A. may be returned for completion. An amended contracted provider dispute that includes the missing information must be submitted to the Alliance within 30 working days of a returned contracted provider dispute.

D. Acknowledgment of Contracted Provider Disputes

The Alliance will acknowledge receipt of all contracted provider disputes as follows:

  • Electronic provider disputes will be acknowledged within two working days of the date of receipt.
  • Paper provider disputes will be acknowledged within 15 working days of the date of receipt.

E. Contact the Alliance Regarding Contracted Provider Disputes

All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to (510) 747-4530.

F. Instructions for Filing Substantially Similar Contracted Provider Disputes

Substantially similar multiple claims, billing or contractual disputes, may be filed in batches as a single dispute, provided that such disputes are submitted in the following format:

  • Sort provider disputes by similar issue
  • Provide cover sheet for each batch
  • Number each cover sheet
  • Provide a cover letter for the entire submission describing each provider dispute with
  • References to the numbered cover sheets.

G. Time Period for Resolution and Written Determination of Contracted Provider Dispute

The Alliance will issue a written determination stating the pertinent facts and explaining the reasons for its determination within 45 working days from the date of receipt of the contracted provider dispute or the amended contracted provider dispute.

H. Past Due Payments

If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, the Alliance will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five working days of the issuance of the written determination.

III. Dispute Resolution Process for Non-Contracted Providers

A. Definition of Non-Contracted Provider Dispute

A non-contracted provider dispute is a non-contracted provider's written notice to the Alliance or its delegated group challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim. Each non-contracted provider dispute must contain, at a minimum, the following information: the provider's name, the provider's identification number, contact information, and:

i. If the non-contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from the Alliance to provider the following must be provided: a clear identification of the disputed item, the date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect;

ii. If the non-contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service, provider's position on the dispute, and an enrollee's written authorization for provider to represent said enrollees.

B. Sending a Non-Contracted Provider Dispute to the Alliance

Contracted provider disputes submitted to the Alliance must include the information listed in Section II.A., above, for each contracted provider dispute. All contracted provider disputes must be sent to the attention of the Claims Department as listed below:

Claims Disputes
Authorization Disputes

NOPD Unit - Claims Department
Alameda Alliance for Health
P.O. Box 2460
Alameda, CA 94501-4506
(Fax) 877-747-4506



C. Time Period for Submission of Provider Disputes

Contracted provider disputes must be received by the Alliance within 365 days after the last date of action that led to the dispute, or in the case of inaction, contracted provider disputes must be received within 365 days after the provider's time for contesting or denying the claim has expired.

Contracted provider disputes that do not include all required information as set forth above in Section II.A. may be returned for completion. An amended contracted provider dispute that includes the missing information must be submitted to the Alliance within 30 working days of a returned contracted provider dispute.

D. Acknowledgment of Non-Contracted Provider Disputes

The Alliance will acknowledge receipt of all contracted provider disputes as follows:

  • Electronic provider disputes will be acknowledged within two working days of the date of receipt.
  • Paper provider disputes will be acknowledged within 15 working days of the date of receipt.

E. Contact the Alliance Regarding Non-Contracted Provider Disputes

All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to (510) 747-4530.

F. Instructions for Filing Substantially Similar Non-Contracted Provider Disputes

Substantially similar multiple claims, billing or contractual disputes, may be filed in batches as a single dispute, provided that such disputes are submitted in the following format:

  • Sort provider disputes by similar issue
  • Provide cover sheet for each batch
  • Number each cover sheet
  • Provide a cover letter for the entire submission describing each provider dispute with
  • References to the numbered cover sheets.

G. Time Period for Resolution and Written Determination of Non-Contracted Provider Dispute

The Alliance will issue a written determination stating the pertinent facts and explaining the reasons for its determination within 45 working days from the date of receipt of the contracted provider dispute or the amended contracted provider dispute.

H. Past Due Payments

If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, the Alliance will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five working days of the issuance of the written determination.

IV. Provider Dispute Resolution Submission Form

Providers can download the Provider Dispute Resolution Submission Form.

V. Claim Overpayments

A. Notice of Overpayment of a Claim

If it has been determined that a claim has been overpaid, the Alliance will notify the provider in writing through a separate notice clearly identifying the claim, the name of the patient, the date of service(s) and a clear explanation of the basis upon which the Alliance believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.

B. Contested Notice

If the provider contests the Alliance's notice of overpayment of a claim, the provider, within 30 working days from the receipt of the notice of overpayment, must send written notice to the Alliance stating the basis upon which the provider believes that the claim was not overpaid. The Alliance will process the contested notice in accordance with the contracted provider dispute resolution process described in Section II above.

C. No Contest

If the provider does not contest the Alliance's notice of overpayment of a claim, the provider must reimburse the Alliance within thirty (30) working days from the provider's receipt of the notice of overpayment of a claim.

D. Offset to claim payments

The Alliance may only offset an uncontested notice of overpayment of a claim against provider's current claim submission when; (i) the provider fails to reimburse the Alliance within the timeframe set forth in Section V.C., above, and (ii) the Alliance's contract with the provider specifically authorizes the Alliance to offset an uncontested notice of overpayment of a claim from the provider's current claims submissions. In the event that an overpayment of a claim or claims is offset against the provider's current claim or claims pursuant to this section, the Alliance will provide the provider with a detailed written explanation identifying the specific overpayment or payments that have been offset against the specific current claim or claims.