Dispute Process

Text Resize

-A A +A
Providers Dispute Process
Jade has a Provider Dispute Resolution (PDR) process that ensures provider disputes are handled in a fast, fair and cost effective manner.

A provider dispute is a written notice from a provider 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 contractual dispute.

How to Submit Provider Disputes
Providers are required to follow the instructions and complete the necessary PDR forms:
Instructions for Submitting Provider Disputes (PDF)
Provider Dispute Resolution and Appeal Request Form (PDF)

Disputes can be sent via US Mail or Fax:
Jade Health Care Medical Group
Attention: Provider Dispute Resolution Area
445 Grant Avenue, Suite 700
San Francisco, CA 94108
Fax: 1-415-955-8815

Resolution Timeframe
Jade will resolve each provider dispute within 45 business days following receipt of the dispute, and will provide the provider with a written determination stating the reasons for the determination.
Non-Contracted Provider Dispute Resolution Process For CMS Medicare Advantage Plan Members
A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the Medicare member regardless of the outcome of the appeal. The medical group cannot undertake a review until or unless such form/documentation is obtained.

Download details of the CMS Non-Contracted Provider Dispute Process (PDF)