Fillable LEVEL 2 PROVIDER COMPLAINT RESOLUTION REQUEST *Level 1 (CalOptima)

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LEVEL 2 PROVIDER COMPLAINT RESOLUTION REQUEST *Level 1 (CalOptima)

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LEVEL 2
PROVIDER COMPLAINT RESOLUTION REQUEST
Updated 9/2012
NOTE: SUBMISSION OF THIS FORM CONSTITUTES AGREEMENT NOT TO BILL THE PATIENT
PRODUCT TYPE: Medi-Cal Commercial/Healthy Families Medicare/OneCare
*Provider Name/ID: Contracted: YES NO
*Provider Billing Address:
*Patient Name:
*Date of Birth:
*Patient CIN/ID #:
Patient Account Number: Original Claim ID Number: (If multiple
claims, use attached spreadsheet)
*Date of Service (From/To): Original Claim Amount
Billed:
Original Claim Amount
Paid:
* DESCRIPTION OF DISPUTE:
EXPECTED OUTCOME:
*
*
Contact Name (please print) Title Phone Number
Signature Date Fax Number
INSTRUCTIONS FOR LEVEL 2 COMPLAINT PROCESS
Please complete the form below. Fields with an asterisk (*) are required.
Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME.
Provide additional information to support the description of the dispute.
Include clean/corrected claim or authorization request, when applicable.
Mail the completed form to: CalOptima Grievance and Appeals Resolution Services
505 City Parkway West
Orange, CA 92868
*Level 1 request must be processed before a Level 2 can be submitted*
*Attach a copy of Level 1 Response and Medical Records not previously submitted*
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LEVEL 2
PROVIDER COMPLAINT RESOLUTION REQUEST
(For use with multiple “LIKE” claims)
Updated 9/2012
Page ______ of ______
Number
* Patient Name
Date of
Birth
* Health Plan ID
Number
Original Claim ID
Number
*Service
From/To
Date
Original
Claim
Amount
Billed
Original
Claim
Amount Paid Expected Outcome Last First
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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LEVEL 2 PROVIDER COMPLAINT RESOLUTION REQUEST *Level 1 (CalOptima)

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Completed 11 March 2021

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