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Provider Dispute Resolution Request Form - LA Care Health Plan

Provider Dispute Resolution Request Form - LA Care Health Plan 2026

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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 and provides mailing instructions for completion.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the required fields marked with an asterisk (*). Start with your provider name, tax ID number, and address for response.
Select your provider type from the options provided, such as MD, Mental Health, or Hospital.
In the CLAIM INFORMATION section, indicate whether you are submitting a single claim or multiple claims. If multiple, complete the attached spreadsheet.
Fill in patient details including name, health plan ID number, and date of birth. Ensure you provide the service dates and original claim number.
Specify the DISPUTE TYPE by selecting from options like Claim or Contract Dispute. Provide a detailed DESCRIPTION OF DISPUTE and EXPECTED OUTCOME.
Complete your contact information including name, title, phone number, and signature before submitting the form.

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

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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 2026

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