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Independent Dispute Resolution Process
The Department of Managed Health Care (DMHC) has established an Independent Dispute Resolution Process (IDRP) to afford non-contracted providers of EMTALA required emergency hospital and physician services a fast, fair and cost effective way to resolve claim payment disputes with health care service plans and their capitated provider groups (collectively referred to as "payers"). The IDRP is voluntary for both non-contracted providers and payers. The IDRP will be overseen by a governing committee consisting of two Payer representatives, two Provider representatives, one consumer representative and two government or DMHC staff members.
In order to submit a claim dispute through the IDRP, the provider must agree that, except for applicable co-payments and deductibles, it will not invoice, balance bill or otherwise seek to collect from the health plan enrollee (patient) any payment for the subject services. In order for the payer to participate, it must agree to pay provider the amount found due, if any, by the IDRP, within fifteen (15) days of receiving notice from the DMHC of the IDRP determination. Participation in the IDRP process does not change a payers' obligation to process and pay the claim within the statutory time period.
The provider will be required to submit IDRP complaint form and a copy of the disputed claim(s) and required supporting documentation. The payer will also be required to provide supporting documentation.
A provider may submit an individual claim or multiple claims (up to 50 claims) that are substantially similar in a single filing. A filing fee will be charged based on the number of claims submitted per dispute. If the payer elects not to participate in the IDRP, the providers' filing fee will be returned.
The IDRP will utilize a "baseball style" arbitration model. In this process, the provider's original billed amount and the payer's original paid amount will be used to determine which amount better reflects the reasonable and customary value of the services performed.
A hospital or institution may elect to submit an alternative amount that is willing to be accepted for the dispute claim(s). If the hospital or institution elects to submit an alternative amount then the payer may also submit an alternative amount that is willing to be paid for the disputed claim(s). These alternative amounts will then be used to determine which amount better reflects the reasonable and customary value of the services performed.
To make that determination, an independent review organization will demonstrate in the findings that he or she has considered the applicability, if any, of the Gould criteria in a determination of which of the party's proposed payment best represents the 'reasonable and customary' value of the services. If other submitted criteria are deemed applicable in that determination, the independent review organization will outline these in the final determination. No determination carries precedential weight.
The provider is encouraged to utilize the payer's internal dispute resolution mechanism prior to submitting a dispute through the IDRP. However, this is not a requirement for providers, other than hospitals. In light of the complexity of hospital claims, hospitals are required to utilize the payer's internal dispute resolution mechanism prior to filing and IDRP complaint form. However, in accordance with existing law, billed charges that are not contested must be paid within the required statutory time period.
For providers that utilize the payer's internal dispute resolution mechanism prior to submitting a dispute through the IDRP, an IDRP decision should be rendered within sixty (60) days of receipt of the provider's dispute form and all required/necessary supporting documentation. If the provider chooses not to first utilize the payer's internal dispute resolution mechanism, the IDRP process will be more costly and may take up to 120 days to render a determination.
The DMHC has retained Maximus as the independent review organization that will review disputes filed through the IDRP. Neither DMHC nor Maximus will intentionally disclose any IDRP submissions or determinations that are specific to the participants, except to the participants themselves, or as required by law.
Voluntary participation in IDRP does not in and of itself waive any rights or remedies it may have against the payer, and that participation in IDRP may not toll any statute of limitations applicable to the exercise of such rights and remedies. Payments determined under the IDRP must be paid within fifteen (15) days of issuance of the decision.
Eligible Claims
The following claim disputes can be submitted by non-contracted physicians, hospitals, institutions, and other licensed health care providers:
- Claim disputes for services rendered after January 1, 2006.
- Claim disputes related to payment amounts only - provider dispute payment amount received.
- Claim disputes exclusively related to late payment are not eligible.
- Disputes that are substantially similar, regarding the same type of service and same payer may be aggregated (up to 50 substantially similar claims per submission).
Ineligible Claims
- Claim disputes that are subject to state/federal court action.
- Claim disputes that are subject to contract terms.
- Late payment disputes.
- Interest payment disputes.
- Medicare claim disputes.
- Medi-Cal claim disputes that are subject to fair hearings.
- Contract claim disputes.
- Other non-state regulated health plans.
- Disputes regarding claims that are not covered benefits.
- Claim disputes not under the Department's jurisdiction.
Fee Schedule
The number of claims submitted for IDRP determines the processing fee. Fees are paid directly to Maximus. Substantially similar claims can be aggregated up to fifty (50) in a single filing. "Substantially similar" claims are those that involve the same or similar services against the same health plan or capitated provider. The following fees are associated with this process and are subject to change without notice:
For claim disputes (other than hospital claims) that have been submitted to the health plan's or capitated provider's internal dispute resolution mechanism:
- 1 individual claim - $25.00
- 2 to 10 claims - $50.00
- 11 to 25 claims - $200.00
- 26 to 50 claims - $300.00
For claim disputes (other than hospital claims) that have NOT been submitted to the health plan's or capitated provider's internal dispute resolution mechanism:
- 1 individual claim - $50.00
- 2 to 10 claims - $100.00
- 11 to 25 claims - $400.00
- 11 to 25 claims - $400.00
- 26 to 50 claims - $600.00
For hospital claim disputes:
- 1 individual claim - $100.00
- 2 to 10 claims - $200.00
- 11 to 25 claims - $400.00
- 26 to 50 claims - $600.00
Dispute Filing Instructions
- Complete an Independent Dispute Resolution complaint form which includes a Filing Coversheet and a Claim Description Form.
- Provide all supporting documentation. This information should include:
- the claim forms submitted to the health plan or their capitated provider;
- a copy of the explanation of payment issued by the health plan or capitated provider;
- a copy of all correspondence between the provider and health plan and/or capitated provider regarding the dispute;
- any medical records submitted to the health plan or capitated provider for claim adjudication;
- a copy of the written determination from the health plan's or capitated provider's internal dispute resolution mechanism (if applicable); and
- a narrative justification regarding your disputed claim(s).
- Send this form with supporting documentation and a check payable to Maximus for your IDRP processing fee within ten (10) working days from the date of receipt to the following address:
Department of Managed Health Care
Provider Complaint Unit
P.O. Box 899
Sacramento, CA 95812-0899
- If you have any questions regarding this form or the IDRP, please call (877) 525-1295 or email to pcu@dmhc.ca.gov.