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.

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 health plan cannot undertake a review until or unless such form/documentation is obtained.

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

Download the Waiver of Liability Statement (PDF).

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

The Centers for Medicare and Medicaid Services (CMS) requires annual fraud, waste and abuse training for organizations providing health, prescription drug, or administrative services to Medicare Advantage (MA) or Prescription Drug Plan (PDP) enrollees on behalf of a health plan. Providers must be knowledgeable with the federal requirements and information regarding fraud, waste and abuse. Please take a moment to go over the provided information in the PDF file link below.

Medicare Fraud, Waste and Abuse and Compliance Training (PDF).

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 9/2023)

Pharmacy Directory – All Plans (PDF)
(No changes made since 5/2023)

Pharmacy Locator