Reimbursement
If a person other than a beneficiary is requesting for a Direct Member Reimbursement, please download and fill out the “Appointment of Representative Form.” Submit the completed form along with the request for reimbursement and any pertinent documentation in order to complete the request to:
Optum/EPIC (for Beaver, Pinnacle, EHP)
PO BOX 530
LA VERNE, CA 91750
EPIC Management LLC (Alliance, Chaffey, Fenix, Redlands Yucaipa)
PO BOX 940
LA VERNE, CA 91750
CLAIMS APPEALS - LISTING OF MEDICARE HEALTH PLAN APPEAL/PROVIDER DISPUTE ADDRESSES
Attention Non-contracted Medicare Providers
Appeals
Process for Non-contracted Medicare Providers
Pursuant to federal regulations governing the Medicare
Advantage program, non-contracted providers may request reconsideration
(appeal) of a Medicare Advantage plan payment denial determination including
issues related to bundling or downcoding of services. To appeal a claim denial,
submit a written request within 60 calendar days of the remittance notification
date prior to January 1, 2025.
After January 1, 2025 To appeal a claim denial, submit a written request within 65
calendar days of the remittance notification date and include at
a minimum:
_ A statement indicating factual
or legal basis for appeal
_ A signed Waiver of Liability form. You may download a copy by clicking here: https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Model-Waiver-of-Liability_Feb2019v508.zip.
_ A copy of the original claim
_ A copy of the remittance
notice showing the claim denial
_ Any additional information,
clinical records or documentation
YOU ARE REQUIRED TO SUBMIT A WAIVER OF LIABILITY FORM FOR ALL RECONSIDERATION/APPEALS.
WAIVER
OF LIABILITY FORM
*Please note: United Healthcare does not handle 2nd level disputes.
DOWNLOAD A PRINTABLE PDF OF ADDRESSES
AETNA MEDICARE HEALTH PLAN
PO BOX 14067
LEXINGTON, KY 40512
FAX #: (724)741-4953
ALIGNMENT HEALTH PLAN
ATTN: PROVIDER APPEALS AND DISPUTES
PO BOX 14012
ORANGE, CA 92863
BLUE SHIELD OF
CALIFORNIA
INITIAL APPEAL RESOLUTION OFFICE
P.O BOX 272620
CHICO, CA 95927-2620
BLUE SHIELD OF
CALIFORNIA
MEDICARE PROVIDER APPEALS DEPARTMENT
P.O BOX 272640
CHICO, CA 95927-2620
BRAND NEW DAY
PO BOX 93122
LONG BEACH, CA 90809
CENTRAL HEALTH MEDICARE PLAN
PO BOX 14246
ORANGE, CA 92863
ELEVANCE HEALTH PLAN / ANTHEM APPEAL AND GRIEVANCE
MAILSTOP: OH205-A537
4361 IRWIN SIMPSON RD.
MASON, OH 45040-9398
PHONE #: 1-888-230-7338
FAX #: 1-888-458-1406
TTY USERS CALL: 711
HEALTHNET
WELLCARE BY HEALTH NET
PROVIDER APPEAL
P.O. BOX 3060
Farmington, MO 63640-3822
https://wellcare.healthnetcalifornia.com/member-resources/member-rights/appeals-grievances/appeals.html
HUMANA INC. APPEALS AND GRIEVANCE DEPARTMENT
PO BOX 14165
LEXINGTON, KY 40512-4165
FAX # (800) 949-2961
INLAND EMPIRE HEALTH PLAN
IEHP DUALCHOICE
P.O. BOX 1800
RANCHO CUCAMONGA, CA 91729-1800
INTER-VALLEY HEALTH PLAN
PO BOX 6002
POMONA, CA 91769
ATTN: PROVIDER APPEALS
SCAN HEALTH PLAN
PO BOX 22698
LONG BEACH, CA 90801
UNITED HEALTHCARE
PO BOX 6106
CYPRESS, CA
90630 MS: CA120-0360
Your claim appeal will be processed according to your
participating contract status with the UnitedHealthcare. Please refer to your
appeal determination notice for information on additional rights you may have
at the conclusion of your appeal review.