Provider Disputes

Provider Dispute Resolution Form

SFHP offers a fair and cost-effective dispute resolution mechanism to providers who are dissatisfied with a claim, billing or contract determination. A Provider Dispute Resolution Request may be submitted in writing using the Provider Dispute Resolution Request Form. Dispute requests must be submitted within 365 days of SFHP’s most recent action on the disputed claim.

If SFHP never received a prior authorization request for services that have now been rendered, please review the retrospective authorization request requirements on SFHP’s Utilization Management Department page.

Retrospective authorization requests must meet at least one of the conditions listed on the Pre-Authorization page and submitted to the UM department no later than 30 calendar days after the date of service. Retrospective authorization requests should not be submitted as Provider Dispute Resolutions (PDRs). PDRs are for claims issues or denied authorizations only.

Minimum Required Information for PDR Submissions
All Provider Dispute Resolution (PDR) submissions must contain the minimum required information listed below. This ensures that your dispute can be processed efficiently and without unnecessary delays.

• Submitter Name: Person or organization preparing the PDR
• Provider Identifier (TIN/NPI): Tax ID Number or National Provider Identifier
• Claim ID: Unique claim identifier
• Date(s) of Service: Exact service dates
• Description of the Dispute: Clearly explain the dispute, including the date of service and reasons for disagreement with the Plan’s action

To ensure compliance and improve processing, submissions missing any required information will be rejected as incomplete.

Denied Authorizations

SFHP allows providers to appeal decisions that resulted in the denial of authorization for clinical services. A provider can file a Provider Dispute Resolution (PDR) to request reconsideration of a UM denial for clinical services that have already been rendered. Please follow instructions on the form when submitting a PDR.

To help ensure the expeditious resolution of the dispute, please include the following:

• A complete, signed Provider Dispute Resolution Request Form, including SFHP’s original claim number and a clear description of the dispute and the expected outcome
• Any relevant, additional documentation that may affect the outcome of the dispute

For further instructions on how to submit a Provider Dispute Resolution Request, please contact SFHP’s Claim Department at 1(415) 547-7818 ext 7115, Monday-Friday, 8:30am – 5:30pm, or email [email protected].