Professional Claims
605 E. Badillo St., #300
Covina, CA 91723
Facility Claims
P.O. Box 371330
Reseda, CA 91337
What are the requirements for a completed claim?
A completed claim must be submitted on a CMS-1500 form for professional services and a CMS-1450 form for hospital/facility services and must have the following information:
Insurance type
Insured’s ID number
Patient’s name
Patient’s birth date
Patient’s address
Diagnosis or nature of Illness or Injury (ICD-9CM code, up to four codes)
Prior authorization number
Date(s) of service
Place of service
Procedures, services or supplies (CPT/HCPCS/NDC Code/Modifier)
Charges for each service billed
Days of units
Federal tax ID number
Provider license or UPIN number
Patient’s account number
Total charges
Signature of physician or supplier, including degrees or credentials (if billed on paper)
Physician billing name, address, zip code
What timeframe do I have to submit a claim if I’m not contracted with you?
We follow the AB1455 requirements. Claims must be received within 180 days of date of service to be considered timely for non-contracted providers.
How do I appeal a claims payment, contested claim or denial?
If you dispute any denial, claims payment, or contested claim, please submit in writing your provider dispute to:
Professional Claims
605 E. Badillo St., #300
Covina, CA 91723
Facility Claims
P.O. Box 31330
Reseda, CA 91337
Your dispute can be submitted by a letter or by a provider dispute form. To obtain a provider dispute form, please contact (626) 974-0440.
Your dispute must contain the following information:
Provider’s name
Provider’s identification number
Provider contract information
A clear identification of the disputed item
Date of service
Please include a clear explanation of the basis upon which you believe the payment amount, contested item, denial or other action is incorrect. Disputes must be submitted and received within 365 days from the date of the last transaction.