This information is intended to inform providers of their rights, responsibilities, and related procedures regarding claims settlement practices and the provider dispute resolution process for Rady Children’s Health Network (RCHN). In accordance with Assembly Bill 1455 (AB 1455), RCHN has established formal policies governing claims payment, dispute timelines, and resolution requirements.
Providers may review the following documents for full details:
- Claims Settlement Practices & Dispute Resolution (AB 1455) – outlines the policies, procedures, and timelines governing claims disputes and appeals.
- AB 1455 Downstream Provider Notice – provides required notification of provider rights and dispute resolution processes under AB 1455.
These documents collectively describe the process RCHN follows when adjudicating claims disputes and ensure compliance with applicable California regulations.
A provider dispute is a provider’s written notice to Rady Children’s Health Network (RCHN) challenging, or appealing a payment of a claim, denial of a claim, adjusted or contested, seeking resolution of a billing determination or other contract dispute, or disputing a request for reimbursement of an overpayment to a claim.
We are dedicated to performing claims payment and provider dispute resolution process as set forth in Sections 1300.71 and 1300.71.38 of Title 28 of the California Code of Regulations.
A reconsideration is defined as a request for review of a claim that you believe was incorrectly paid or denied because of a processing error.
A claim that is stamped as either a ‘resubmission’ or ‘reconsideration’ is not
considered a dispute or an appeal. Claims received in our provider dispute and
appeals department as a ‘claim correction’ will be handled as a corrected claim.
How to file a dispute
- Download the Provider Dispute Resolution Request form.
- Fill out the form and attach supporting documentation.
- Mail the completed form and documents to:
Rady Children’s Health Network
Attn: Claims Department MC 5077
3020 Children’s Way
San Diego, CA 92123
Time period for submission of provider disputes
Provider disputes must be received by Rady Children’s Health Network within 365 calendar days from RCHN’s action that led to the dispute (or the most recent action if there are multiple actions) that led to the dispute.
Provider disputes that do not include all required information may be returned to the submitter for completion. An amended provider dispute that includes the missing information may be submitted to Rady Children’s Health Network within 30 working days of the receipt of a returned provider dispute.
Acknowledgment letter
Rady Children’s Health Network (RCHN) will acknowledge receipt of all provider disputes as follows:
- By mail: Within 15 working days of receipt
If you do not receive an acknowledgment letter, please contact RCHN at 877-276-4543.
Processing time
RCHN will issue a written statement with the pertinent facts and explaining the reasons for the dispute determination within 45 days.
Decision letter
If the decision is in favor of the provider, payment is made with applicable interest within 5 working days of the decision. Interest due will be calculated in accordance with Assembly Bill 3275, effective January 01, 2026.
Second-level disputes
Providers who are not satisfied with the decision after completing the dispute
process may seek relief by filing a second-level appeal with the member’s health
plan.