How to Submit Disputes & Appeals

To submit a dispute, complete the appropriate PDF form below, save it and fax it to SCAN:

• Reopening Request Form: Use this form for SCAN processed claims
• Payment Dispute Resolution (PDR) Form: Use this form for Non-Contracted Provider Payment disputes
• Provider Delegate Claim Dispute Resolution Form: Use this form when requesting SCAN assistance with Delegate disputes

The preferred and most efficient method to submit Claim Disputes to SCAN is by Fax.

• Fax Disputes and any attachments to (562) 997-1835
• If unable to fax, mail the form and supporting documents to: SCAN Health Plan, Attn: SCAN Claims Provider Disputes, P.O. Box 22698, Long Beach, CA 90801-9826

Please allow the following processing times for disputes:

• Thirty (30) calendar days for non-contracted providers for fee schedule payment disputes, billing errors, and minor corrections
• Forty Five (45) calendar days for Medicaid
• Sixty (60) calendar days for contracted providers

 

Check status of Provider Dispute
Providers can submit an inquiry via the SCAN Portal to check status on Provider Dispute only if both of the following occurred:

• Provider previously submitted a Provider Dispute and has not yet received a Resolution Letter; and
• Processing timeline for a dispute or appeal as stated in the Provider Dispute & Appeals section has been exceeded.
• If above two items have been met, provider can proceed to submit an inquiry. However, they must first sign into the Provider Portal at www.scanhealthplan.com/providers.
• Go to “Resources and Guidelines” tab then the “Provider Eligibility and Claims Transactions” section. Scroll down and click on “Provider Disputes & Appeals” folder to locate form and follow instructions.

 

• Non-Contracted Providers may request an appeal within sixty (60) calendar days of receipt of Remittance Advice (RA).
  
  
• The appeal request must include a signed Waiver of Liability (WOL) form, documentation supporting the request (e.g., copy of RA notice, medical records, and copy of the claim). The WOL form holds the member harmless regardless of the outcome of the appeal.
  
  
• The preferred and most efficient method to submit appeal to SCAN is by Fax.
  - Fax the completed WOL form and any attachments to (562) 989-0958
  - If unable to fax, mail the completed WOL form and any documentation to: SCAN Health Plan, Attn: SCAN Non-Contracted Provider Appeals, P.O. Box 22616, Long Beach, CA 90801-9826

• Please allow Sixty (60) days for processing time for Non-Contracted Provider Appeals. The adjudication timeframe begins when the WOL is received by the plan.

Check status of Non-Contracted Provider Appeal
Provides can submit an inquiry via the SCAN Portal to check status on Non-Contracted Provider Appeal only if both of the following occurred:

• Provider previously submitted a Non-Contracted Appeal and has not yet received a Resolution Letter; and
• Processing timeline for a dispute or appeal as stated in this section has been exceeded.
• If above two items have been met, provider can proceed to submit an inquiry. However, they must first sign into the Provider Portal at www.scanhealthplan.com/providers.
• Go to “Resources and Guidelines” tab then the “Provider Eligibility and Claims Transactions” section. Scroll down and click on “Provider Disputes & Appeals” folder to locate form and follow instructions.