Provider claims and dispute resolution regulations

For Blue Shield of California Promise Health Plan providers

Providers can voice questions and concerns to the Blue Shield of California Promise Health Plan Provider Services Department by calling, mailing a letter, sending an email, or visiting in person.

If a provider would like to appeal or dispute a claim payment, the provider must submit it in writing by mail or fax to the Blue Shield Promise Provider Dispute and Resolution Department. If a provider attempts to file a dispute by phone, Blue Shield Promise will assist the provider in filing the dispute in writing. All appeals and disputes are entered in the Provider Dispute Database for investigation, and providers will receive a written response.

For more information about the process, see the instructions for providers by line of business:

Blue Shield Promise Medicare provider dispute resolution policy and procedures

Blue Shield Promise Medi-Cal provider dispute resolution policy and procedures

Blue Shield Promise Cal MediConnect provider dispute resolution policy and procedures

For Blue Shield of California providers

Regulations required by §1371.38, et al, of the Health & Safety Code (added to law by AB1455), became effective August 25, 2003. Health plans and capitated providers regulated by the Knox-Keene Health Care Service Plan Act of 1975 must be fully compliant with §1300.71 and 1300.71.38 of Title 28 of the California Code of Regulations (CCR) by January 1, 2004.

Effective January 1, 2006, the Insurance Code was amended by SB 367 and SB 634 to extend to providers who contract with carriers regulated by the Department of Insurance many of the rights that providers have in contracting with Knox-Keene plans. Blue Shield Life & Health Insurance Company (Blue Shield Life), a wholly-owned subsidiary of Blue Shield of California (Blue Shield), accesses the Blue Shield provider network. The AB 1455 provider rights provisions have been extended to providers contracting with Blue Shield Life.

Blue Shield has taken steps to ensure that claims processing and provider dispute resolution mechanisms are compliant with requirements established by state law for provider claims and dispute resolutions. The AB 1455 Provider claims and dispute resolution compliance summary (PDF, 52 KB) provides an overview of actions Blue Shield has taken as well as actions that are required of providers.

Information about fee schedules, provider appeal mechanisms, claim submission timelines, directions to claims submission and refund requests is available in the Claims section of the Provider Connection.

For additional information about provider claims practices and dispute resolution requirements, view the following documents:

Blue Shield's Provider claims and  dispute resolution regulations summary (PDF, 145 KB)

AB 1455 Provider claims and cispute resolution regulations (full text) (PDF, 172 KB)