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Consumer: Health Care Providers Guide to the Complaint Process
(June 22, 2006)

Introduction

Existing law provides for the Insurance Commissioner to establish a program to investigate and respond to complaints concerning health insurers. Under existing law, a health insurer is required to reimburse a provider's claim within a specified time frame or to provide a notice to the provider explaining its reasons for denying or contesting the claim. This guide was created to inform health care providers of their right to file a complaint with the California Department of Insurance (CDI) regarding the handling of a claim or other obligation under a health insurance policy by a health insurer or agent, or regarding the alleged misconduct by a health insurer or agent.

Who Regulates What Type of Health Plan?

The majority of California's health plans are regulated by either the California Department of Insurance (CDI) or the California Department of Managed Health Care. The CDI regulates point-of-service health plans and certain Preferred Provider Organization (PPO) health plans underwritten by health insurance companies authorized by the CDI.

The CDI does not regulate Health Maintenance Organizations (HMOs) or certain PPOs, which fall under the Knox-Keene Act (i.e. Blue Cross of California or Blue Shield of California). Complaints against these types of health plans should be submitted to:

Department of Managed Health Care (DMHC)
980 Ninth Street #500
Sacramento, CA 95814-2725
Website: www.dmhc.ca.gov
Provider Complaints (877) 525-1295

A list of health insurance companies regulated by the Department of Insurance is provided. For a list of the HMOs and other health care service plans regulated by the Department of Managed Health Care, please visit the DMHC Website.

The California Department of Insurance does not regulate self-insured health plans, even in cases where the plan is administered by a health insurance company. Most self-insured health plans fall under the jurisdiction of Employee Retirement Income Security Act (ERISA). ERISA is federal law that is enforced by the U.S. Department of Labor, Employee Benefits Security Administration (DOL-EBSA). If you have a complaint against a self-insured health plan through an employer or union, then contact the DOL-EBSA for assistance at (866) 275-7922 or you can visit their Website at: www.dol.gov/ebsa. However, the DOL-EBSA does not regulate self-insured health plans that are sponsored through school districts, other municipalities, and churches. If the insured is a member of this type of plan, he/she can file a complaint with the plan directly or may seek a legal remedy through a court of law.

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Before You Submit A Provider Complaint

Dispute Resolution Mechanism

  • Before you file a complaint with the California Department of Insurance, you must first submit the dispute to the insurer's Dispute Resolution Mechanism. Under the Dispute Resolution Mechanism process, disputes must be submitted to the insurer in writing and include the following information: provider name, provider tax identification number, patient name, insurer's identification information, dates of service, description of dispute, and if applicable, billed and paid amounts.
  • Insurers must provide the procedures for submitting a dispute through the Dispute Resolution Mechanism, including the location and telephone number where information regarding disputes may be submitted.
  • Insurers must also ensure that a Dispute Resolution Mechanism is accessible to non-contracting providers for the purpose of resolving billing and claims disputes.
  • Insurers are required to resolve each dispute and issue a written determination within 45 working days of the receipt of the provider's dispute.

Filing A Complaint With The California Department of Insurance

Once you have determined that the plan is regulated by the CDI and have submitted a dispute to the insurer for review under the Dispute Resolution Mechanism process, and you disagree with the decision or would like the California Department of Insurance to review an issue, you may submit a complaint by completing a Health Care Provider Request for Assistance (HPRFA). To ensure proper review of the case, the following documents should be sent to the Department:

  • A copy of the completed Health Care Provider Request for Assistance Form.
  • A copy of the patient's Assignment of Benefits documentation.
  • A copy of claim forms submitted to the insurance company.
  • Copies of all correspondence between the provider and the insurance company, including all related Explanation of Benefits (EOB).
  • A copy of the Dispute Resolution Mechanism process determination letter.
  • A copy of the patient's insurance identification card.
  • A copy of the provider's contract with the insurance company, if any.

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Examples of the Types of Problems That You Can Submit to the CDI
  • Improper denial or delay in payment of a claim
  • Other claims handling issues
  • Dispute Resolution Mechanism difficulties
  • Misconduct of the health insurer

Examples of Complaints Which Do Not Fall Within the Jurisdiction of the CDI

  • Workers Compensation Claims
  • Knox-Keene Health Care Service Plans
  • Medi-Cal
  • Medicare
  • Self-funded Employee Benefit Plans

How to Submit a Complaint to the CDI

You may submit a complaint to the Department of Insurance by completing a Health Care Provider Request for Assistance (HPRFA) for each claim submitted to the insurer. You may request a HPRFA to be mailed to you by calling our Consumer Hot-line toll-free number (800) 927-HELP (4357). You may also download the HPRFA. (This document is in (PDF) format. To download a free Acrobat Reader, visit our free document readers page.)

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