Claims Information

What address are paper claims to be mailed to?

All paper claims must be mailed to:

Professional Claims
605 E. Badillo St., #300
Covina, CA 91723
Facility Claims
P.O. Box 31330
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.