Claims


The Claims Department representatives are there to answer questions and resolve issues that providers may have regarding claims.  Our Claims Module simplifies the process by allowing our providers to save time and money with quick and easy access.  Our provider web portal allows the provider’s office to submit their claims electronically, review claims status, claims history and payment online.  CCMSO is able to accept various claim forms, UB-04, CMS-1500, PM160, and Charge Tickets.  Our Claims Department is staffed with experienced and knowledgeable personnel so that the providers for our IPA’s can feel confident that they will be properly addressed.


 To assist providers, below are some important instructions:

CLAIM SUBMISSION:

Paper Claims (CMS 1500, UB04, PM160)

MAIL CLAIMS TO:

CRYSTAL COAST MSO, LLC
ATTN: Claims Department
20377 SW Acacia Street, Suite 120
Newport Beach, CA 92660-0781

FAX CLAIMS TO: (714) 495-2054


Electronic Claims


OFFICE ALLY

Payer ID Code: SHIPA

DIRECT EDI
Please call our IT Department at (714)

WEB PORTAL SUBMISSION

Please fills out our Web Portal Provider Application to request access to our provider web portal. For any questions regarding the form, please contact Provider Contracting at (714) 808-8960.

FEE SCHEDULES:

For a listing of the fee schedules, please click on the links below:


CLAIMS DISPUTE RESOLUTION PROCESS FOR CONTRACTED PROVIDERS


Definition of Contracted Provider Dispute

A contracted provider dispute is a provider’s written notice to IPA 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, and provider’s contact information.

If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from the IPA to a contracted provider the following must be provided:

A clear identification of the disputed item, the Date of Service, a clear explanation of the basis upon which the provider believes the payment amount is incorrect, a request for additional information, a request for the reimbursement for the overpayment of a claim, contest, denial, adjustment or other disputed action.

If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider’s position on the issue must be submitted. If the contracted provider dispute involves a member or multiple members, the name and identification number(s) of the member(s), a clear explanation of the disputed item, the Date of Service, the provider’s position on the dispute and the member’s written authorization for the provider to represent said member(s).

Contracted Provider Dispute to IPA

Contracted provider disputes submitted to the IPA must include the information listedinSection A, above, for each contracted provider dispute. All contracted providerdisputesmust be sent to the attention of Provider Relations Director and the Director of Utilizationand Quality Management at:



Mail Claims To:
CRYSTAL COAST MSO, LLC
Attn: Provider Dispute/Provider Appeals
20377 SW Acacia Street, Suite 120
Newport Beach, CA 92660-0781
Or
Fax Claims To: (714) 495-2054



Time Period for Submission of Provider Disputes regarding Claims

Contracted provider disputes must be received by IPA within 365 days from provider’s action that led to the dispute, (or the most recent action if there are multiple actions) that led to the dispute. In the case of inaction, contracted provider disputes must be received by the IPA 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.

Contracted provider disputes that do not include all required information as set forth above in Section 13.2A may be returned to the submitter for completion. An amended contracted provider dispute which includes the missing information may be submitted to the IPA within 30 working days of your receipt of a returned contracted provider dispute.

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


  • Electronic - Contracted provider disputes will be acknowledged by the IPA within two (2) working days of the Date of Receipt by the IPA.
  • Paper - Contracted provider disputes will be acknowledged by the IPA within fifteen (15) working days of the Date of Receipt by the IPA.


Contacting the IPA Regarding Contracted Provider Disputes

All inquiries regarding the status of a contracted provider dispute or about filing acontractedprovider dispute must be directed to the IPA at (714) .

Instructions for Filing Substantially Similar Contracted Provider Disputes

Substantially similar multiple claims, billing or contractual disputes may be filed in batches asasingle dispute, provided that such disputes are submitted in the followingformat:


  • Sort provider disputes by similar issue
  • Provide cover sheet for each batch
  • Number each cover sheet
  • Provide a cover letter for the entire submission describing each provider dispute with references to the numbered coversheet


Time Period for Resolution and Written Determination of Contracted Provide Dispute

The IPA will issue a written determination stating the pertinent facts and explainingthereasons for its determination within forty-five (45) working days after the Date of Receipt ofthecontracted provider dispute of the amended contracted providerdispute.

Past Due Payments

If the contracted provider dispute of amended contracted provider dispute involves a claimandis determined in whole, or in part, in favor of the provider, the IPA will pay anyoutstandingmonies determined to be due, and all interest and penalties required by law orregulation,within five (5) working Days of the issuance of the writtendetermination.

CLAIMS DISPUTE RESOLUTION PROCESS FOR NON-CONTRACTED PROVIDER APPEALS:

The dispute resolution process for non-contracted providers is the same process as the contracted providers dispute as set forth above.