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Provider Dispute Resolutions with Managed Care Plans
Act
by Aug 20, 2026
Effective date
Aug 20, 2026
Identified
Aug 21, 2026
Summary
This policy clarification updates provider dispute resolution eligibility for Medi-Cal Managed Care Plans, specifically clarifying that non-contracted providers with a letter of agreement or single case agreement where service was authorized are eligible to receive reimbursement at the agreed-upon rate for covered services when the member was eligible and enrolled on the date of service. The policy reiterates that all MCPs must have a fast, fair, and cost-effective dispute resolution mechanism available, and providers can dispute unpaid claims (after 30 days), claim denials, or lack of response within 30 days of clean claim submission.
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What to do
by Aug 20, 2026 · 4 steps
01Billing team must review and update provider dispute resolution procedures to reflect the clarified eligibility for non-contracted providers with letters of agreement or single case agreements.
02Ensure that: (1) all disputes are submitted only after a clean claim has been submitted and not paid within 30 days, OR after a denial is received, OR after 30 days with no response; (2) contact information and submission methods for each contracted MCP's dispute resolution process are documented in billing workflow; (3) staff understand that non-contracted providers with agreements are eligible for reimbursement at agreed-upon rates when members were eligible and enrolled on date of service; (4) dispute submissions are tracked through MCP provider portals where available.
03Train billing staff on the distinction between clean claims (required before disputing) and incomplete claims (which must be resubmitted).
04Document the MCP dispute resolution process location (contract, provider manual, or website) for each plan.
If missed: Failure to follow proper dispute procedures may result in claims being denied or disputes being rejected.
Original notice
Provider Dispute Resolutions with Managed Care Plans
mcweb.apps.prd.cammis.medi-cal.ca.gov · Always check the source before changing claims.