Provider Dispute Resolution Forms

The information and forms provided on this page are for Non- Contracted Providers ONLY. Health Plan of San Joaquin / Mountain Valley Health Plan (“Health Plan”) contracted providers should sign into DRE for PDR information and submissions.

• If you are trying to submit corrections on a claim, please follow the Corrected Claim submission guidelines.
• If a claim was denied as a duplicate and you feel it denied in error, please make sure it was submitted with the appropriate documentation, modifiers or corrected claim submission indicator before you submit a dispute.
• If a claim or claim line was denied for supporting documentation, please submit as Correspondence with the requested information.

Form Download

Please select the form you would like to download from the following choices:

Providers can request immediate recoupment for overpayments where we issued a demand letter. By using the immediate recoupment process, providers may avoid submitting a check and interest assessments.

You can submit the request for an overpayment(s) related to a specific demand letter or for all future overpayments.