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VHP is committed to ensuring that its providers and members can resolve issues through its grievance and appeals process. VHP does not discriminate against providers or members for filing a grievance or an appeal. Providers are prohibited from penalizing a member in any way for filing a grievance. Furthermore, VHP monitors its grievance and appeals process as part of its quality improvement program and is committed to resolving issues within established timeframes, referring specific cases for peer review when needed.
Section I: Provider Disputes
Provider Dispute Resolution Procedure and Process It is the policy of VHP to establish an expeditious, fair, and efficient dispute resolution mechanism to process and resolve disputes. Per Assembly Bill 1455, a provider has up to 365 calendar days to file a dispute from the date of last action taken by VHP. A letter of acknowledgement will be sent via U.S. mail within 15 days of VHP receiving a completed provider dispute paper form. VHP will send a resolution letter within 45 business days. Use the following link to download the Provider Dispute Form: https://www.valleyhealthplan. org/sites/p/fr/Forms/Documents/Provider-Dispute-Form-Final.pdf. The Provider Dispute Form is also located in the Appendix. Completed Provider Dispute Forms can be submitted to: Valley Health Plan Provider Dispute Resolution P.O. Box 28387 San Jose CA 95159 Phone: 408.885.7380
Dispute Resolution Mechanism Each provider dispute must contain at least the following information and be submitted on the form referenced above: 1. Provider National Provider Number (NPI) 2. Provider Tax Identification Number (TIN) 3. Provider contact information, including complete provider name and mailing address 4. Member/patient name and member ID number 5. Member date of birth 6. Patient account number, if applicable 7. VHP claim number, date of service, original claim amount billed, and original claim amount paid 8. Dispute description, including any documentation supporting the dispute
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CH 15: Provider Disputes & Member Grievances & Appeals
