As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and a process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This information notice is intended to inform you of your rights, responsibilities, and procedures for claim payment and provider dispute resolution for commercial HMO, POS, and, where applicable, PPO products where Mills Peninsula Medical Group (“MPMG”) is delegated to perform claims payment and provider dispute resolution.   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.

I. Claim Submission Instructions 

        A. Sending Claims to MPMG.  Claims for services provided to members assigned to MPMG must be sent using one of  the following routes:

Via Mail:        MPMG Claims Department

P. O. Box 4348

Burlingame, CA 94011-0469

Via Physical Delivery:    MPMG Claims Department

                                577 Airport Blvd, Suite 300

                                Burlingame, CA 94010

Via Claims Clearinghouse:  MPMG will accept electronic claims submitted through ClaimsREDI (DDD) , MedAvant or Office Ally

Via MPMG Website: Contact Provider Relations for details. Claims must be in the HIPAA compliant 837p or 837i formats.

For more information on ClaimsREDI, please visit their Web site at www.claimsredi.com.

For more information on MedAvant Healthcare Solutions, please visit their Web site at www.medavanthealth.com.

For more information on Office Ally, please visit their Web site at www.officeally.com. 

B. Calling MPMG Regarding Claims. For claim filing requirements or claim status inquiries, you may contact MPMG’s Customer Service Department by calling:  650-240-8059.

C. Claim Submission Requirements. The following is a list of claim timeliness requirements, claim supplemental information and claim documentation required by MPMG:

i. Timely Claims Submission Policy

All commercial claims must be submitted to MPMG within six (6) months from the date of service. Claims submitted after the 6-month deadline will be denied payment. Providers may not bill members for claims denied due to late submission.

If a member has dual coverage and MPMG is the secondary payor, then the provider has six (6) months from the date the primary payor processed the claim to submit the claim to MPMG. This date appears on the primary payor’s Explanation of Benefits (EOB).

ii. Billing & Coding Standards 

MPMG providers shall bill in a manner consistent with MPMG standards, which include but are not limited to, applying current Centers for Medicare & Medicaid Services (“CMS”), American Medical Association (“AMA”), and/or Current Procedural Terminology (“CPT”) guidelines to the codes on the claim. 

The purpose of coding standards is to establish guidelines for MPMG providers to use to ensure accurate reporting of services provided to MPMG members.  These standards apply to all MPMG providers.

For additional information on MPMG’s billing and coding standards, please refer to MPMG’s Provider Office Manual or go to www.MPMG.com.   

iii. Claim Form Requirements

MPMG providers must bill on CMS 1500 (or equivalent) claim form using standard CPT, ICD-9, HCPCS, and DSMIII coding methodologies for procedure codes and diagnosis codes.  All codes must be current and valid as of the date of services billed.  Please include a detailed description for all codes that do not have a standard description or are miscellaneous codes.   

iv. Operative Report

MPMG providers must submit an Operative Report when billing for codes that have not been pre-authorized by MPMG Referral Services. If MPMG Referral Services Department has authorized all codes on the claim then providers do not need to automatically send an Operative Report along with their claims.

v. Referral Forms

MPMG providers do not need to send copies of their MPMG referral forms to the Claims Department.

D. Claim Receipt Verification.  MPMG providers may verify that MPMG has received a claim by using one of the following methods:

        i. Electronic: Use ProviderNet to look up claim status, emailed acknowledgements are generated and sent back to the submitter’s email address validating submission date, file ID, total count broken out by total accepted, pended,rejected.

ii. Phone:  Call our Customer Service Department at 650-240-8059.

iii. Email:  Email Customer Service Department at  custserv@mpmg.com 

DISPUTE TYPE

II.  Dispute Resolution Process for Contracted Providers

A. Definition of Contracted Provider Dispute.  A contracted provider dispute is a provider’s written notice to MPMG and/or the member’s applicable health plan 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 MPMG 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 MPMG.  To submit a dispute to MPMG, Provider must use a “Provider Dispute Resolution Form.” which includes all of the information listed in Section II.A. (Please refer to Attachment A.)  The “Provider Dispute Resolution Form” also is available at www.MPMG.com.  All contracted provider disputes must be sent to the attention of Customer Service Provider Dispute Unit using one of the following routes:

    Via Mail:                       MPMG -- Provider Dispute Unit

P. O. Box 4348

Burlingame, CA 94011-0469

    Via Physical Delivery:       MPMG Provider Dispute Unit

577 Airport Blvd, Suite 300

Burlingame, CA 94010

    Via email:   custserv@MPMG.com 

    Via Fax:   650.240.0900

C. Time Period for Submission of Provider Disputes.  

i. Contracted provider disputes must be received by MPMG within 365 days from MPMG’s  action that led to the dispute (or the most recent action if there are multiple actions) that led to the dispute, or  

ii.   In the case of MPMG’s inaction, contracted provider disputes must be received by MPMG within 365 days after the provider’s time for contesting or denying a claim (or most recent claim if there are multiple claims) has expired. 

iii. Contracted provider disputes that do not include all required information as set forth above in Section II.A. may be returned to the submitter for completion.  An amended contracted provider dispute which includes the missing information may be submitted to MPMG within thirty (30) working days of your receipt of a returned contracted provider dispute.  

D. Acknowledgment of Contracted Provider Disputes.  MPMG will acknowledge receipt of all contracted provider disputes as follows:

 Paper:  Contracted provider disputes will be acknowledged by MPMG within fifteen (15) Working Days of the Date of Receipt by MPMG.

E.  Contact MPMG 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 Customer Service Provider Dispute Unit at: 650.240.8059.

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:

Please use the “Provider Dispute Resolution Form.”  (Please refer to Attachment A.)  Please check the “Multiple ‘LIKE’ Claims” box in the Claim Information section and complete the spreadsheet.  The “Provider Dispute Resolution Form” also is available at www.MPMG.com.  

G. Time Period for Resolution and Written Determination of Contracted Provider Dispute. MPMG will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) Working Days after 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 (see Section II. C. iii above) involves a claim and is determined in whole or in part in favor of the provider, MPMG will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) 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 MPMG 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 MPMG 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 enrollee.

B. Dispute Resolution Process.  The dispute resolution process for non-contracted Providers is the same as the process for contracted Providers as set forth in sections II.B., II.C., II.D., II.E., II.F., II.G., and II.H. above.  

IV. Claim Overpayments

A. Notice of Overpayment of a Claim. If MPMG determines that it has overpaid a claim, MPMG will notify the provider in writing through a separate notice clearly identifying the claim, the name of the member, the Date of Service(s) and a clear explanation of the basis upon which MPMG 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 MPMG’s notice of overpayment of a claim, the provider, within 30 Working Days of the receipt of the notice of overpayment of a claim, must send written notice to MPMG stating the basis upon which the provider believes that the claim was not overpaid. MPMG will process the contested notice in accordance with MPMG’s contracted provider dispute resolution process described in Section II above. 

C.  No Contest. If the provider does not contest MPMG’s notice of overpayment of a claim, the provider must reimburse MPMG within thirty (30) Working Days of the provider’s receipt of the notice of overpayment of a claim. 

D.   Offsets to payments. MPMG may only offset an uncontested notice of overpayment of a claim against provider’s current claim submission when; (i) the provider fails to reimburse MPMG within the timeframe set forth in Section IV.C., above, and (ii) MPMG’s contract with the provider specifically authorizes MPMG 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, MPMG 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.