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Health: Provider Complaints Jurisdictional Issues
Examples of the types of problems that you may submit to the California Department of Insurance:
- 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 come within the jurisdiction of the California Department of Insurance:
- Workers Compensation Claims The California Department of Insurance primarily deals with rating and underwriting issues involving Workers Compensation insurance. The California Department of Industrial Relations, Division of Workers Compensation administers the Workers Compensation claims in California. You can contact the Information and Assistance Unit of the Division of Workers Compensation by calling 800-736-7401 or visit DIR's Website.
- Knox-Keene Health Care Services Plans (HMOs, certain PPOs): The Department of Managed Health Care regulates and licenses Health Maintenance Organizations (HMOs) and some Preferred Provider Organizations (PPOs), such as Blue Cross of California. You can contact DMHC by calling 888-466-2219 or visiting DMHC's Website.
- Medi-Cal: For issues regarding Medi-Cal, contact Medi-Cal by calling 800-541-5555 or visiting Medi-Cal's Website.
- Medicare: Medicare is a federal program and does not come under state jurisdiction. For issues regarding Medicare, contact Medicare by calling 800-633-4227 or visiting Medicare's Website
- Self-funded Employee Benefit Plans: Most self-insured health plans fall under the 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). You can reach DOL-EBSA by calling 866-444-3272 or by visiting DOL-EBSA's Website.
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