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. Providers may submit complaints involving health care services rendered on or after January 1, 2006. 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.
The following steps are designed to provide health care providers with information and assistance: Step 1 - Jurisdictional Issues, Step 2 - Supporting Documents, Step 3 - Health Care Provider Request for Assistance Form (HPRFA).
Step 1: Jurisdictional Issues