A copy of the completed Health Care Provider Request for Assistance form (HPRFA) and other documentation submitted by you will be provided to the insurance company, agent or broker. To ensure proper review of the case, the following documents should be sent to the California Department of Insurance:
- A copy of the completed Health Care Provider Request for Assistance form (HPRFA)
- Copy of the patient's (signed) Assignment of Benefits, if applicable
- 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) EOBs
- Copy of the Dispute Resolution Process determination letter
- Copy of the patient's insurance identification card - both sides
- Copy of the provider's contract with the insurance company, if any
Do not send us originals of any documents, photographs or other evidence as we are not responsible for lost records or other items. The more complete the information we receive, the quicker we can identify the issues and begin our review.
The time it takes to handle a Health Care Provider Request for Assistance will vary greatly, depending on how complex the matter is. Please be assured, your request will be handled as quickly as possible. If more than ten business days have passed without contact from us, please call our Consumer Hotline at 800-927-HELP (4357).
(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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