ProAct respects the provider’s right to dispute; however we would much prefer to address your particular issues without a formal dispute.  We encourage you to first contact your Network Development Representative or contact the Network Management Department at 800-570-7414 Extension 46.

If you do not receive a satisfactory resolution to your issue and wish to formally file a dispute, it must be submitted in writing to: Director of Network & Reimbursement Management, ProAct Health Solutions, 2940 Mallory Circle, Suite 201, Celebration, FL 34747

The Network Management Department will acknowledge receipt of your dispute within one working day and will endeavor to respond to your communication within one calendar week.

Provider Violations and Dispute Resolution

In order to respect providers’ rights while simultaneously protecting consumers, ProAct maintains a formal mechanism to address participating provider alleged violations and resolve participating provider disputes.  This Dispute Resolution Process is available to any participating provider when ProAct takes an action that changes the network status.  The Dispute Resolution Process is not available for certain types of issues, issues like:

  • Repeated non-performance of obligations without corrective action
  • Revocation of medical licensure
  • Violations of professional standards
  • The commission of unlawful acts

These situations constitute Termination for Cause, as outlined in the Contract.  The ProAct Dispute Resolution Process is congruous with the contract between ProAct and providers who deliver services.  The formal Dispute Resolution Process is documented and reviewed at least annually by the Credentialing Committee.   The Chief Dental Director and at least one licensed participating provider sits on the Credentialing Committee.

Addressing Alleged Violations

All participating provider alleged violations of ProAct’s contractual requirements or the provider’s competency or conduct are addressed.  All reports of violations are investigated and actions are taken according to the findings and the appropriate disciplinary steps outlined in the contract.  A corrective action process may or may not be implemented prior to a decision to terminate, based on the type of violation as determined by the Credentialing Committee.

Providers’ Rights to Dispute

All participating providers have the right to dispute provider status actions taken by ProAct, and are informed of their rights to this Dispute Resolution process upon being accepted into the provider network.  Providers must submit all Dispute requests in writing.  The Dispute request must include:

  • The nature of the problem
  • Previous attempts, if any, to resolve the issue, and
  • Any other pertinent information.

The provider may submit all information in writing, either by electronic mail, surface mail, or other source of written communication.

Review of Professional Conduct or Competency Disputes

If the dispute is related to Professional Conduct/Competency, a Peer Review Panel is formed and convened to review the dispute.

Peer Review Panel (First-Level review)

The first-level peer review panel includes at least three qualified individuals, with one of those individuals being a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider who has filed the dispute.  The panel carefully and thoroughly reviews all the information surrounding the case, including all information that the provider who filed the dispute presents to ProAct to support his/her case.  The findings and determination of the First Level Panel Review are summarized in writing and this notification is sent to the provider via mail within 20 business days of the receipt  of the Dispute request.  Included in the written notification is information about the participating provider’s right to reconsideration by a second-level and the methods to request such reconsideration.

Peer Review Panel (Second-Level review)

A second-level peer review panel is formed when requested by a provider due to dissatisfaction with the first-level peer review panel’s decision. This panel includes at least three qualified individuals who did not participate on the first-level panel review, with one of those individuals being a participating provider who in not otherwise involved in network management and who is a clinical peer of the participating provider who has filed the dispute.  As with the first-level panel, the provider being reviewed may submit additional information that he/she deems important to support his/her case.  The findings and determination of the Second Level Panel Review are summarized in writing and this notification is sent to the provider via mail within 20 business days of the receipt of the request for reconsideration.  A statement is included in the written notification informing the provider that this is the final determination regarding this case.

Review of Administrative Disputes

Administrative disputes are cases that do not involve issues of professional competency or conduct that result in a change in provider status.  Administrative cases are reviewed by a designated ProAct staff member who was not involved in the initial decision that is the subject of the dispute.  The findings and determination of the administrative dispute review are summarized in writing and this notification is sent to the provider via mail within 20 business days of the receipt of the Dispute request.  This review and determination is the first and  final level of review for Administrative disputes.