6.2 Provider Disputes

6.2.1 Provider Questions, Concerns and Disputes
Providers can communicate questions and concerns to Care 1st Provider Network Operations Department by telephone, e-mails, in writing or in person. Many of these questions and concerns can be addressed very quickly by Provider Network Operation Administrators. All provider disputes must be submitted in writing by mail, e-mail, or facsimile to Care 1st Health Plan Grievance Unit. If a provider attempts to file a dispute via telephone, Care 1st staff will assist the provider to file the dispute in writing by physical or electronic means. The provider dispute process and provider dispute form is available on the Care 1st Website at www.Care1st.com. All disputes entered in the Provider Dispute log will be investigated and a response will be provided in writing.

6.2.2 Provider Disputes Policy and Procedure
Providers has 365 days of the Plan’s action or the Plan’s capitated provider’s action or, in the case of inaction to submit a written dispute to Care1st Health Plan’s Grievance Unit. Disputes may pertain to such issues as the authorization or denial of a service or the processing, payment or nonpayment of a claim, capitation issues or other issues. All written formal disputes will be responded to in writing. Upon receipt of the written dispute specifying the issue of concern, it will be logged on the Provider Dispute log. An acknowledgement letter will be sent to the provider within 15 working days of receiving the Paper dispute and 2 working days for the electronic dispute.

Any provider dispute submitted on behalf of a member, will be handled through the member grievance process.

Care1st Health Plan shall send a written closure letter with the resolution to the provider within 45 working days of receipt of the Grievance. Care1st shall retain all documentation related to the peer review in accordance with section 53310 of the California Code of Regulation. All files shall be maintained for five years.

6.2.3 First Level Appeal
A provider may appeal the decision made at Care1st Health Plan. Care1st will refer clinical provider appeals and other appropriate cases for professional peer review.

When the appeal is referred to professional peer review:

1. All parties concerned shall be notified that a referral has been made to professional peer review and that a final determination may require up to 45 working days from the acknowledgment of the receipt of the dispute.
   
2. The professional peer review shall make its evaluation and submit its findings and recommendations to the Plan and the Provider within 45 working days after the receipt of the dispute and all background information is supplied.

   Care1st, after taking into consideration the findings and recommendations of the professional peer review, shall send a written closing letter outlining its conclusions within 45 working days of receipt of the Appeal. Language in the letter will include the next appeal steps the provider can take with the issue. Care1st shall retain all documentation related to the peer review in accordance with section 53310 of the California Code of Regulation. All files shall be maintained for five years.

6.2.4 Second Level Appeal
A Provider may, after completing a first level appeal, submit a second level appeal. A second level appeal must be filed within 180 calendar days of receipt of the Plan's written report of its conclusion. It can also be used when Care1st has failed to act within the deadlines set forth above.

In the case of Medi-Cal a second level appeal for a dispute can be filed with L.A. Care or Care 1st. The Provider shall submit the following:

1. A letter requesting a review of the first level appeal.
   
2. A copy of the letter sent to Care1st requesting a first-level appeal.
   
3. A copy of the original documents submitted to Care1st
   
4. A copy of the first level appeal - denial response letter if the second level of appeal is based on a denial.
   
5. A copy of any other correspondence between Care1st and the Provider that documents timely submission and the validity of the appeal.

Care1st or L.A. Care shall acknowledge the second level appeal request by a Provider within 15 working days of its receipt. If the appeal is sent to L.A. Care they shall send written notice to Care1st of the appeal. Care 1st or L.A. Care shall review the written documents submitted in the Provider's appeal, may ask for additional information, and may hold an informal meeting with the involved parties. LA Care shall send a written report of its conclusions and reasons to the Provider and the Plan within 45 working days of receipt of the appeal from the Provider.

6.3 Reconsideration
A provider will have the ability to furnish the Care1st Grievance Unit with any additional information/documentation that may have a bearing on the final determination of a request for authorization that has been previously denied, deferred, and/or modified.

PROCEDURE

1. A provider requesting reconsideration may call, fax or submit in writing or electronically any additional information to the Care1st U.M. Department to support the original authorization request.
   
2. A reconsideration request will occur within one business day upon receipt of the provider telephone call or the written or faxed request.
   
3. The additional information will be reviewed by the Care1st Chief Medical Officer (CMO) or designated peer reviewer.
   
4. If the CMO or designated peer reviewer reverses the original determination based on additional information provided by the provider, an approval letter will be sent to the provider and the member.
   
   If reconsideration does not resolve a difference of opinion, the provider may then submit an appeal grievance in writing to the Care1st Appeals/Grievance Department.