Dispute Resolution for Commercial and CHP Plans
This chapter contains processes for our members and practitioners to dispute a determination that results in a denial of payment or covered service.
Glossary terms found on this page:
A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.