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Health: Provider Complaints

The Health Care Provider complaints section is designed to assist with resolving complaints regarding improper denial or delay in payment of a claim, other claims handling issues, Dispute Resolution Mechanism difficulties, and misconduct of the health insurer.  The California Insurance Code defines health insurance as an individual or group insurance policy that provides coverage for hospital, medical, or surgical benefits.  Before you file for a case review with the California Department of Insurance, you should first exhaust the Dispute Resolution (DR) process with the insurance company. The insurer is required to resolve each provider dispute consistent with applicable law and issue a written determination within 45 working days after the date of receipt of the provider dispute.

To ensure proper review of the case, copies of the following documents should be sent along with the completed Health Care Provider Request for Assistance (HPRFA) form:

  • The patient's Assignment of Benefits, if applicable
  • Claim forms submitted to the insurance company
  • All correspondence between the provider and the insurance company, including all related Explanation of Benefits (EOBs)
  • Dispute Resolution Process determination letter
  • Patient's insurance identification card - both sides
  • Provider's contract with the insurance company, if any

Health Care Provider Request for Assistance Form (HPRFA)

(Note: You will need Adobe Acrobat Reader in order to view, download, or print the HPRFA form.  To download the free Adobe Acrobat Reader, please see the Free Document Readers page.)

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