Provider Complaint Against a Plan

Provider Complaint Against a Plan

The DMHC recognizes that it is important for hospitals, doctors and other providers to be paid promptly and accurately, and our Provider Complaint process is offered as a means of ensuring prompt payment.

Before the DMHC can begin a review, the provider is required to submit the dispute to the payor's Provider Dispute Resolution (PDR) mechanism for a minimum of 45 working days or until receipt of the payor's written determination, whichever period is shorter.

Appropriate supporting documentation is a prerequisite for a review of any issue. Upon submission of your complaint, an acknowledgement of the receipt of your complaint will be e-mailed along with a complaint number, and a list of the required supporting documentation and instructions for submitting the documentation.

Unfair Payment Pattern and Emerging Trend Analysis will be performed on ALL provider complaints. Trending data will support the routine and non-routine financial examinations performed by the Department’s Office of Financial Review.

Emergency Services Independent Dispute Resolution Process (EMTALA IDRP)

The DMHC established an Emergency Services Independent Dispute Resolution Process (IDRP) to afford non-contracted providers who deliver Emergency Medical Treatment & Active Labor Act (EMTALA) required emergency services a fast, fair and cost-effective way to resolve claim payment disputes with health care service plans or capitated providers concerning the “reasonable and customary” value of services rendered. The Emergency Services IDRP is voluntary and non-binding as to both providers and payors.

For more information regarding the Emergency Services IDRP and how to file a claim.

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Non Emergency Services Independent Dispute Resolution Process (AB 72 IDRP)

New legislation enacted in 2016 (AB 72) established the Non-Emergency Services IDRP. AB 72 protects consumers from surprise medical bills for non-emergency services rendered by  non-contracting providers at contracted facilities on or after July 1, 2017. AB 72 also takes consumers out of any ongoing billing disputes by creating a binding IDRP to allow non-contracting providers and payors to dispute the appropriate reimbursement amount for non-emergency services. The Department has contracted with an independent dispute resolution organization for the AB 72 Non-Emergency Services IDRP, which began processing disputes on September 1, 2017.

For more information regarding the Non Emergency Services IDRP and how to file a claim.