Provider Dispute Resolution

Providers have the right to appeal and dispute payment determinations made on behalf of our managed medical groups. 

Submission Directions

Providers may submit Dispute and Appeal Requests via mail.

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Requests must contain:

• Copy of Original CMS 1500

• Signed Waiver of Liability 

• Explanation of Request

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Medical Group should be referenced in address line to facilitate sorting of Appeal / Dispute for prompt processing. 

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"Medical Group Name c/o Golden Coast MSO"

Attn: Provider Dispute Resolution

PO BOX 1296

RIVERSIDE, CA 92502