For Providers
Everything You Need to Support Your Champion Health Plan Members
Plan resources, forms, and network support for Champion Health Plan providers.
Your Partner in Care
Built for the Way You Practice
Champion Health Plan supports providers with the plan information, forms, and network resources you need to care for shared members. Find current benefit summaries, claims and formulary information, and provider forms below, or reach out to join our direct network.
Provider Portal
Log in to manage claims, check eligibility, and access member information.
Plan Resources by Year
Summary of Benefits, claims submission requirements, formulary, and provider search by plan year.
Forms & Documents
Clinical criteria and other provider forms and reference documents.
Fraud, Waste & Abuse Reporting
Report suspected FWA or compliance concerns confidentially, as a contracted provider or FDR.
Claim Status & Inquiries Check claim status, payment information, and remittance details.
The Champion Health Plan Provider Portal is the preferred method for contracted providers to verify:
- Claim status
- Payment information
- Remittance details
Access the Provider Portal:
Click Here
To register for portal access:
- Select the Champion Health Plan
- Select First Time User
- Complete Login Form
*Please request user access using the above URL.
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For EDI Claims, EDI Encounters, Paper Claims, and Paper Encounters, refer to:
claims@championpayer.com
For General Claim Inquiries refer to:
Claims Inquiry Department
Phone: 1 (800) 885-8000 | TTY 711
Hours: Monday – Friday 8 am to 5 pm Pacific Time
Timely Filing Requirements Deadlines and exceptions for submitting initial claims for reimbursement.
Providers must submit initial claims within 180 calendar days from the date of service, unless otherwise specified in the provider agreement.
Claims submitted after 180 days may be denied unless:
- Good cause is demonstrated
- Delay resulted from coordination of benefits
- Retroactive eligibility applies
- Another exception applies under federal law
Timely filing limits do not supersede Medicare appeal deadlines under 42 CFR §422.582.
Clean Claim Payment Standards Payment timeframes for clean claims in California and Nevada.
California (DMHC-Regulated Plans)
Champion Health Plan processes claims in accordance with:
- California Health & Safety Code §1371
- Title 28 CCR §1300.71
Clean claims will be paid or denied within:
- 30 working days (electronic claims)
- 45 working days (paper claims)=
Interest will accrue on improperly delayed payments as required by California law.
Nevada (DOI-Regulated Plans)
Champion Health Plan processes claims in accordance with applicable Nevada insurance law.
Clean claims will be paid or denied within:
- 30 calendar days (electronic claims)
- 45 calendar days (paper claims)
Interest may accrue in improperly delayed payments as required by Nevada law.
HMO-POS Out-of-Network Services Payment methodology, authorization, and billing rules for POS benefit services.
Champion Health Plan may offer a Health Maintenance Organization – Point of Service (HMO-POS) product that allows members to obtain certain covered services from non-contracted providers.
Payment Methodology
For covered services rendered under the POS benefit:
- Champion Health Plan pays non-contracted (POS) provider claims at 100% of the Medicare allowable amount,
- Subject to applicable member cost-sharing,
- And subject to prior authorization requirements when applicable.
Primary Care Services and Urgent Care Services are generally covered under the in-network HMO benefit structure and are not eligible for routine POS reimbursement unless otherwise authorized or required under federal regulations.
Authorization Requirements
POS services may require prior authorization in accordance with:
- 42 CFR §422.105
- Plan Evidence of Coverage (EOC)
- Plan medical management policies
Failure to obtain required authorization may result in claim denial.
Member Cost-Sharing
Members accessing POS services may have higher cost-sharing than for in-network services, as described in the applicable Evidence of Coverage.
Balance Billing
Non-contracted providers furnishing services under the POS benefit:
- May not bill members for covered services beyond applicable cost-sharing and amounts permitted under federal law.
- Must accept the Plan payment plus applicable member cost-sharing as payment in full for covered POS services.
Out-of-network providers remain under no obligation to treat Champion Health Plan members except in emergency situations.
Provider Dispute Resolution How to submit and resolve disputes over claim payment, denial, or adjustment.
California Provider Dispute Resolution (PDR)
In accordance with:
- California Health & Safety Code §1367
- Title 28 CCR §1300.71.38
A provider dispute is a written notice challenging:
- Claim payment
- Denial
- Adjustment
- Bundling
- Contractual interpretation
Submission Deadline (California)
Within 365 calendar days from:
- Date of payment/denial/adjustment; or
- Date of the event giving rise to the dispute
Resolution Timeframes (California)
Champion Health Plan will:
- Acknowledge receipt within 15 working days (if required)
- Resolve disputes within:
- 45 working days (contracted providers)
- 30 working days (non-contracted providers)
Nevada Provider Disputes
Providers must submit disputes within 12 months (365 days) from the contested action unless otherwise specified by contract.
Champion Health Plan will resolve disputes within applicable Nevada regulatory timeframes.
Submission Address (All States)
Champion
PO Box 15337
Long Beach, CA 90815-9995
Submit electronically through your clearinghouse.
Payer ID #: CPS01 (use a “zero,” not the letter “o”)
Provider Dispute Resolution Form (PDF)
Electronic submission may be available via the Provider Portal.
Medicare Advantage Appeals Steps for requesting reconsideration of denied claims, including non-contracted provider appeals.
Under 42 CFR §422.566–422.626:
Providers may request reconsideration of the claims denied.
Non-Contracted Providers
In accordance with 42 CFR §422.562(c)(2):
A non-contracted provider may appeal a denied claim if a completed Waiver of Liability (WOL) is submitted.
By signing the WOL, the provider agrees:
- To waive any right to collect payment from the member (except cost-sharing)
- Not to bill the member regardless of the appeal outcome
Appeals must be filed within 60 calendar days from the organization’s determination.
If upheld, the appeal is forwarded to a CMS-contracted Independent Review Entity (IRE).
Further levels include:
- Administrative Law Judge
- Medicare Appeals Council
- Federal District Court
Expedited reconsiderations may be requested under 42 CFR §422.584.
Appointment of Representative Requirements for a provider or third party to represent a member during an appeal.
Under 42 CFR §422.561, members may appoint a representative.
CMS Form 1696 or equivalent documentation is required when a provider or third party represents a member in an appeal.
An AOR remains valid for one year unless revoked.
Coordination of Benefits Guidelines for identifying other coverage and billing primary payers correctly.
Champion Health Plan coordinates benefits in accordance with:
- Medicare Secondary Payer rules (42 CFR Part 411)
- 42 CFR §422.108
Providers must:
- Identify other coverage
- Bill primary payers first when applicable
- Submit accurate COB data
- Refund overpayments promptly
Emergency Services Coverage rules for emergency and post-stabilization care, no prior authorization required.
(42 CFR §422.113)
Emergency services are covered without prior authorization.
An emergency medical condition is defined as a condition with acute symptoms of sufficient severity such that a prudent layperson could reasonably expect the absence of immediate medical attention to result in:
- Serious jeopardy to health
- Serious impairment of bodily functions
- Serious dysfunction of any bodily organ or part
Champion Health Plan:
- Covers emergency services nationwide
- Covers post-stabilization services as required
- Will not retrospectively deny coverage if the prudent layperson standard is met
Balance billing for covered emergency services is prohibited.
Delegation of Oversight How Champion Health Plan oversees First Tier, Downstream, and Related Entities.
Champion Health Plan may delegate certain functions to First Tier, Downstream, and Related Entities (FDRs).
In accordance with 42 CFR §422.503 and §422.504:
- Champion Health Plan retains full accountability
- Conducts audits and oversight
- Requires FWA and compliance training
- Requires OIG/GSA exclusion screening
- Monitors delegated entities
False Claims Act (Federal & State)
Champion Health Plan complies with:
- Federal False Claims Act
- California False Claims Act
- Nevada False Claims provisions
- CMS Program Integrity requirements
Prohibited conduct includes:
- Submitting false claims
- Making false statements
- Retaining known overpayments
- Avoiding obligations owed to the government
Penalties may include treble damages, civil penalties, and exclusion.
Whistleblower protections apply.
Reporting Fraud, Waste, and Abuse
Compliance & Ethics Hotline (24/7)
Phone: 1-800-885-8000 | TTY 711
Fax: 949-998-9856
Email: hotline@championpayer.com
Hours: Monday – Friday 8 am to 5 pm Pacific Time
Reports may be made anonymously and are investigated confidentially.
Important Regulatory Notices Key compliance reminders for billing, overpayments, and network participation.
- Non-contracted providers may not bill members for covered services beyond applicable cost-sharing.
- Providers must comply with CMS, DMHC (California), and DOI (Nevada) requirements.
- Overpayments must be reported and returned in accordance with 42 CFR §422.326 and applicable state law.
- Out-of-network providers are not obligated to treat members except in emergency situations.
This information is not a complete description of benefits. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year.
Champion Health Plan is a Medicare Advantage organization with a Medicare contract. Enrollment in Champion Health Plan depends on contract renewal.
Providers must comply with all applicable federal Medicare Advantage regulations (42 CFR Part 422), California Department of Managed Health Care (DMHC) requirements, Nevada Division of Insurance (DOI) requirements, and all other applicable federal and state laws.
This page was last updated on 9/1/2026. Pending CMS approval.