Submit a Provider Complaint

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 You Submit a Complaint

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 to the DMHC, 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.

Review of provider complaints is limited based on staffing available to conduct these reviews. When a case review has been initiated, the DMHC will open a case file and will request the provider to submit relevant documentation. Upon receipt of the documentation, the DMHC will determine whether there is non-compliance with the provisions of the Knox-Keene Act. In many instances, a case review will make a determination of whether claims should have been paid, or whether interest is due. In-depth analysis of the results of case reviews will also supplement the findings of Emerging Trend Analysis.

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. 

Types of Provider Complaints

  • Individual Complaints
  • Multiple Complaints (up to 50 claims per complaint)
  • Emergency Services Independent Dispute Resolution Process (IDRP)
  • Non-Emergency Services Independent Dispute Resolution Process (AB72 IDRP)

Does My Complaint Qualify?

Eligible Claims
  • The services were rendered within the last four years.
  • Provider Dispute Resolution (PDR) has been filed through the responsible payor's Provider Dispute Resolution mechanism and you have received a written determination or the appeal has been pending within that process for more that 45 working days.
  • The claim dispute is with a health plan, Medical Group, or Independent Physicians' Association (IPA) that is contracted with a health plan licensed under the Knox-Keene Act. A list of all Knox-Keene Act licensees is available for your review. 
Ineligible Claims
  • The services were rendered beyond the last four years.
  • Provider Dispute Resolution (PDR) has not been filed through the responsible payor's Provider Dispute Resolution mechanism and/or you have not received a written determination or the appeal has not been pending for more than 45 working days.
  • The claim dispute is with a health plan, Medical Group, or Independent Physicians' Association (IPA) that is contracted with a health plan not licensed under the Knox-Keene Act. A list of all Knox-Keene Act licensees is available for your review. 
  • The claim dispute is with a health plan licensed or regulated by another state.
Department Jurisdiction

The DMHC is only able to review complaints against Knox-Keene Act licensees. The Department does not have jurisdiction over the following plans or products:


Submit a Provider Complaint 

 

For more information about the complaint process, please review our FAQ.

Need Assistance? Call the Provider Complaint line toll-free at 1-877-525-1295.


Provider Complaint Statistics

The Department's Provider Complaint Unit tracks and trends provider complaints submitted by California providers. The posted statistical information reflects the provider complaint activity for each calendar year quarter.

2016 Provider Complaint / Dispute Issues Statistics

2015 Provider Complaint / Dispute Issues Statistics

2014 Provider Complaint / Dispute Issues Statistics

2013 Provider Complaint / Dispute Issues Statistics

2012 Provider Complaint / Dispute Issues Statistics

2011 Provider Complaint / Dispute Issues Statistics

2010 Provider Complaint / Dispute Issues Statistics

2009 Provider Complaint / Dispute Issues Statistics

2008 Provider Complaint / Dispute Issues Statistics