If services have not been rendered, providers with permission from the member, may file a Member Appeal within sixty (60) days of the notice of action letter for Medi-Cal members and 180 days for Healthy Workers HMO and Healthy Kids HMO. SFHP will provide a written resolution for a Member Appeal within thirty (30) days.
SFHP only has one level of appeal for denied authorizations; denials that are upheld by SFHP cannot be appealed again. Therefore, please gather all relevant documentation and clinical information that may affect the outcome of the dispute before submitting the appeal.
Providers contracted with delegated medical groups or who have provided services to members assigned to a delegated medical group must follow the medical group’s appeals process for the first level review. After an authorization has been denied, the provider may submit an appeal to the medical group following the medical group’s appeals process. The medical group’s clinician evaluating this request should be other than the clinician who issued the original denial. If the denial is upheld during the First Level Review, the provider may submit an appeal request to SFHP with the medical group’s denial letter and appeal resolution letter attached. The appeal must be submitted to SFHP within 90 days of the first level review decision. Appeals submitted to SFHP for second level review will follow SFHP’s criteria and procedures.
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 submit a retrospective authorization request to SFHP’s Utilization Management Department.
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 firstname.lastname@example.org.