Claims settlement practices, dispute resolution mechanism

Provider Notice

As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This notice is intended to inform you of your rights, responsibilities, and related procedures as they relate to claim settlement practices and claim disputes. 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.

1. Claim Submission Instructions:

   1. Sending Claims to Valley Health Plan: If you are contracted directly with Valley Health Plan, send claims to:
      
      VHP Commercial  
      Employer Group Claims  
      P.O. Box 26160
      San Jose, CA 95159
      
      Valley Health Plan HMO
      Covered California Claims
      Valley Health Plan
      P.O. Box 26160
      San Jose, CA 95159
      
      Valley Health Plan HMO
      Individual & Family Plan Claims
      Valley Health Plan
      P.O. Box 26160
      San Jose, CA 95159​
   2. Claim Submission Requirements:  The following is a list of timeliness requirements, supplemental information and documentation required when submitting claims to Valley Health Plan:
      1. Contracted providers must submit claims within 90 days or according to your agreement terms.  Non-contracted providers have 180 days after the date of service to submit a claim. Claims submitted outside of these time frames may be denied as untimely.
      2. Submit claims with all reasonably relevant information to determine payer liability and to ensure timely processing and payment.
      3. Non-contracted providers must submit a completed IRS Form W-9 with all claims.
      4. If services are rendered to a Valley Health Plan member by a provider outside of California, a completed IRS Form 587 must be submitted.
      5. If services are rendered to a Valley Health Plan member by a provider in California and the provider’s pay to address is not a physical address, a completed IRS Form 590 must be submitted.
      6. If Valley Health Plan is the secondary payor, then providers must submit the primary payor Explanation of Benefits (EOB) documentation with applicable claims in order to coordinate benefits.
   3. Claim Receipt Verification: Valley Health Plan will acknowledge the date of claim receipt within two (2) business days of the date of receipt of an electronic claim and within fifteen (15) business days of the date of receipt of a hard copy claim. The following is an alternate list of methods by which a provider can readily confirm receipt of claim and recorded date of receipt.
      1. For VHP Commercial, Covered California, and Individual & Family claims - call Valley Health Plan’s Claims Department at (408) 885-4563
   4. Valley Health Plan Payment and Billing Policies: Valley Health Plan billing and payment policies are consistent with Current Procedural Terminology (CPT) guidelines, and standards accepted by nationally recognized medical societies and organizations federal regulatory bodies and major credentialing organizations.
      1. Valley Health Plan reviews billing codes for appropriateness and adjusts claim payments accordingly.
      2. Reimbursement for immunizations and injectable medications are in accordance with CPT guidelines and applicable state laws or regulations.
   5. Non-Contracted Provider Reimbursement Policy: Non-contracted provider claims will be paid in accordance with VHP's Non-Contracted Provider Reimbursement Policy.
   6. Coding: Valley Health Plan recognizes modifiers in accordance with CPT and HCPC guidelines.

Provider Dispute Process

As required by California Assembly Bill 1455, VHP has established a fast, fair and cost effective dispute resolution mechanism that complies with the DMHC requirements. The dispute process as described in the Provider Relations section of this Manual offers providers a method of resolving claims disputes.  A claim dispute may be submitted in writing to:

Valley Health Plan
Attn: Provider Relations Dispute Resolution
P. O. Box 28387
San Jose, CA 95159

Dispute Resolution Mechanism

Each provider dispute must contain at least the following information:

​​a) Provider's name.
b) Provider's identification number.
c) Provider contact information.
d) Member name and Plan ID
e) Any documentation supporting the dispute.
f) Original Claim number
g) Reason for Dispute​

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:

a) Sort disputes by similar issues/type and separate into batches.  If dispute is related to claims, it must include the required information for each claim.
b) Provide cover sheet for each batch.
c) Number each cover sheet.
d) Provide a cover letter for the entire submission describing each provider dispute with references to the numbered cover sheets.

Provider disputes that do not include all required information may be returned for additional information; VHP will clearly identify in writing to provider the missing information necessary to resolve the dispute.  Provider may submit an amended provider dispute setting forth the missing information within 30 working days.

If the provider initiates a dispute to contest a claim or request reimbursement of an overpayment of a claim the provider must also provide a clear identification of the disputed item and the date(s) of service. Provider must also explain clearly the basis for provider's belief that the payment, request for overpayment return, request for additional information, contest, denial or adjustment, or other action is incorrect.

1. Claim Overpayments
   1. Notice of Overpayment of a Claim:  If Valley Health Plan determines that it has overpaid a claim, they will notify the provider in writing through a separate notice clearly identifying the claim, the name of the patient, the date of service(s) and an explanation of the basis upon which Valley Health Plan believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.
   2. Contested Notice: If the provider contests Valley Health Plan’s notice of overpayment of a claim, the provider, within 30 business days of the receipt of the notice of overpayment of a claim, must send written notice to Valley Health Plan stating the basis upon which the provider believes that the claim was not overpaid. Valley Health Plan will process the contested notice in accordance with Valley Health Plan’s contracted provider dispute resolution process described in Section II above.
   3. No Contest: If the provider does not contest Valley Health Plan’s notice of overpayment of a claim, the provider must reimburse Valley Health Plan within 30 business days of the provider’s receipt of the notice of overpayment of a claim.
   4. Offsets to Payments: Valley Health Plan may only offset an uncontested notice of overpayment of a claim against provider’s current claim submission when
      1. The provider fails to reimburse Valley Health Plan within the timeframe set forth in Section IV.C., above, and
      2. Valley Health Plan’s contract with the provider specifically authorizes Valley Health Plan 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, Valley Health Plan 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.

2. Fee Schedules

   1. Effective April 1, 2014, the following fee schedules may be used as the basis for Valley Health Plan’s payments to you as a non-contracted provider.
      
      The Medicare Fee Schedule can be found online at:
      https://www.cms.gov/Medicare/Medicare.html
   2. For questions regarding fee schedules, contact
      Valley Health Plan Attention:
      Provider Disputes Department
      2480 N. First Street, Suite 200
      San Jose, CA 92131
      Phone: (408) 885-2221

3. Notification of Amendments to Valley Health Plan’s Claims Settlement and Dispute Resolution Processes

   1. Valley Health Plan shall provide 45 days advance notice to contracted providers of any material revision to its Claims Settlement Processes, Dispute Resolution Mechanism and Fee Schedules.
   2. For further information regarding AB1455 Regulations, please refer to the California Department of Managed Health Care’s website​.