PROVIDER COMPLAINT RESOLUTION REQUEST
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:
*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
Original Claim Amount
* DESCRIPTION OF DISPUTE:
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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