Claims/Provider Dispute Resolution

AmericasHealth Plan (AHP) Provider Dispute Resolution (PDR) Process

Contracted Providers

A Medicare contracted provider does not have the ability to appeal a claim payment but can request AHP to re-review a claim payment, also known as a "payment dispute". Refer to your particular contracting arrangements to solve your disputes. Please log-in to the AHP portal for specific information using the following link: AHP PDR Form

Definition of a Provider Dispute

A provider dispute is a written notice from the non-contracting provider to AHP that:

  • Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested.

  • Challenges a request for reimbursement for an overpayment of a claim.

  • Seeks resolution of a billing determination or other monetary dispute.

The following conditions are not considered PDR’s:

  • Submission of corrected claims.

  • Submission of claims for retro review.

    • If the Claims Department has requested that you send medical records, please submit your request to the claims department along with a claim.

The following information is provided for non-contracted providers:

Provider Dispute Time Frame

Non-contracted providers have 365 days from the Plan’s action or the Plan’s capitated provider's action or, in the case of inaction, to submit a written dispute to AHP Provider Dispute & Resolution (PDR) Department. Upon receipt of the written dispute specifying the issue of concern, it will be logged on the Provider Dispute & Resolution Database. An acknowledgement letter will be sent to the provider within 15 working days of receiving the paper dispute.

Medicare

  • All written formal disputes will be responded to in writing.

  • The PDR Department will review and prepare a written explanation, no later than 60 calendar days to the provider from the date it receives the request for a payment dispute.

  • Please complete and include in your dispute a fully executed Waiver of Liability (WOL) Statement. You may obtain the WOL using the following link: AHP PDR Form.

Commercial

  • All written formal disputes will be responded to in writing.

  • The PDR Department will review and prepare a written explanation, no later than 45 working days to the provider from the date it receives the request for a payment dispute.

Submission of Provider Disputes

When submitting a provider dispute, a provider should use a Provider Dispute Resolution Request form. If the dispute is for multiple, substantially similar claims, complete the spreadsheet on page 2 of the Provider Dispute Resolution Request Form.

Submit PDR’s to the following address:

AmericasHealth Plan (AHP)
Attention: PDR Department
P.O. Box 2459
Camarillo, CA 93011

Or Fax to

Attention: PDR Department
(805) 200-4961

For immediate assistance, please call (800) 633-3313 (TTY 711).