Provider Resources

Submitting Claims Electronically

Balance prefers claims be submitted electronically.  For information, please call our Member Services.

Submitting Paper Claims

All paper claims must be submitted using a CMS 1500 form (for professional providers) and a UB-92 form (for institutional providers).

Send paper claims to:

Balance by CCHP
Claims Department
PO Box 1599
San Leandro, CA 94577

Balance 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 for 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 must use a Provider Dispute Resolution and Appeal Request Form (PDF).

You may download Instructions for Submitting Provider Disputes (PDF) or call Balance Provider Dispute Relations at 1-628-228-3214 for assistance.

Disputes can be mailed to:

Balance by CCHP
Attn: Provider Dispute Resolution Area
445 Grant Avenue
San Francisco, CA 94108

Disputes can also be faxed to 1-415-955-8815.

Resolution Timeframe

Balance 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.

Contracting and non-contracting providers can contact Utilization Management at 1-877-208-4959 to request to obtain prompt authorization.

Download your very own copy of the Balance by CCHP Provider Manual – Revised 6/29/20.

Please call, email, or submit the form if you find any inaccuracies with the provider information on our website. You can also use this page to report any changes in the provider’s information such as phone number, language, and location.

1. Telephone: 1-628-228-3485
2. Email: [email protected]
3. Online Form

A Balance plan drug list, a comprehensive formulary and a pharmacy locator can be found below under Drug List. If you have any questions, please contact Member Services.

Effective July 1, 2014, the new Prescription Drug Prior Authorization Request Form is required for non-Medicare plans. View (Section 1300.67.241) (PDF) to read the complete DMHC regulations specifying the process.

(New) Prescription Drug Prior Authorization Request Form (PDF) (Uploaded 02/2018)

Formulary for Individual, Family and Covered CA

Pharmaceutical Management Procedures (PDF)

Formulary (List of Covered Drugs) for Commercial Plans
(No changes made since 3/2024)

Pharmacy Directory – All Plans (PDF)
(No changes made since 4/2024)

Pharmacy Locator