Home
Forms Library
Provider Dispute Resolution Request Form - LA Care Health Plan

Provider Dispute Resolution Request Form - LA Care Health Plan 2025

Provider Dispute Resolution Request Form - LA Care Health Plan Preview on Page 1

Show details

4.1 out of 5

52 votes

The document is a Provider Dispute Resolution Request form from Sharp Rees-Stealy Medical Group, designed for healthcare providers to formally dispute billing determinations or claim issues. It outlines the necessary information required for submission, including provider details, claim information, and a description of the dispute along with the expected outcome. The form emphasizes that submission indicates an agreement not to bill the patient.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to rapidly redact Provider Dispute Resolution Request Form - LA Care Health Plan online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Dochub is the greatest editor for updating your forms online. Follow this straightforward guideline edit Provider Dispute Resolution Request Form - LA Care Health Plan in PDF format online at no cost:

Sign up and sign in. Register for a free account, set a strong password, and proceed with email verification to start managing your templates.
Add a document. Click on New Document and select the form importing option: upload Provider Dispute Resolution Request Form - LA Care Health Plan from your device, the cloud, or a protected link.
Make changes to the sample. Take advantage of the top and left panel tools to edit Provider Dispute Resolution Request Form - LA Care Health Plan. Insert and customize text, pictures, and fillable fields, whiteout unneeded details, highlight the important ones, and provide comments on your updates.
Get your paperwork accomplished. Send the form to other people via email, generate a link for faster document sharing, export the sample to the cloud, or save it on your device in the current version or with Audit Trail added.

Explore all the benefits of our editor right now!

See more Provider Dispute Resolution Request Form - LA Care Health Plan versions

We've got more versions of the Provider Dispute Resolution Request Form - LA Care Health Plan form. Select the right Provider Dispute Resolution Request Form - LA Care Health Plan version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2022	4.7 Satisfied (45 Votes)
2008	4 Satisfied (24 Votes)
2003	4.1 Satisfied (52 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is the LA Care Health Plan the same as Medi-Cal?

L.A. Care is the health plan for Medi-Cal members in Los Angeles County. The California Department of Health Care Services (DHCS) works with L.A. Care to provide your Medi-Cal health care.

How do I appeal a DHCS provider?

The appeal process is available to any participant, his/her representative or treating provider who disputes denial of payment for a service or the denial, deferral or modification of a service by the primary care physician (PCP) or any member of the interdisciplinary team (IDT) who is qualified to make referrals.

What is provider dispute resolution?

A provider dispute is a written notice from the non-participating provider to Health Net that: Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested.

How do I appeal my Louisiana Healthcare Connections provider?

If you feel you need a fast appeal decision, call 1-866-595-8133 (TTY: 711) and ask for the Appeals department. Our Medical Director will make a decision on your request and we will let you know within 72 hours (3 days).

How do I talk to a representative at L.A. Care?

If you are an L.A. Care member and have questions, we encourage you to contact our Member Services department for assistance at 1-888-839-9909 (TTY 711). Please call Member Services for your specific plan if you need assistance.

How do I appeal my LA Care Health Plan attention member services?

If you need help asking for an appeal or with Aid Paid Pending, we can help you. We can give you no-cost language services. Call Member Services at 1-888-839-9909 (TTY: 711).

How do I appeal a Medi-Cal decision?

A. Use this two-step process: It used to be that you could file for fair hearing within 90 days of the date of the NOA. NOW, it is a two-step process: first, appeal to your managed care plan within 60 days of receipt of the ABD, and second, file for a fair hearing within 120 days of the date you received the NAR.

How do I file a grievance with L.A. Care?

You can submit an online Grievance Form. By Phone: Call L.A. Care Member Services at 1-888-839-9909 (TTY: 711) 24 hours a day 7 days a week including holidays. Give your health plan ID number, your name and the reason for your complaint.

Provider Dispute Resolution Request Form - LA Care Health Plan 2025

Here's how it works

How to rapidly redact Provider Dispute Resolution Request Form - LA Care Health Plan online