Site Map > Health Care Providers > Claim Issues > Reporting a Problem to the Department
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Welcome
Health care providers are a crucial part of California's health care delivery system. The Department regulates medical groups with regard to certain requirements that apply to them under the Knox-Keene Act. You may report problems with a medical group using the methods described above.
- General Information
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IMR Information
Reporting a Problem to the Department
If you would like to report a problem regarding claims payment, please complete an online Provider Complaint form.
For individual complaint disputes you wish to submit, please complete an Individual Provider Complaint Form. For multiple "like" complaint disputes you wish to submit, please complete a Multiple Provider Complaint Form. This will enable the Department to commence a substantive review, which may identify system patterns or problems with particular health plans or capitated providers.
Before reporting a problem with a health plan, you should verify that the Department regulates the plan. To view a list of the plans regulated by the Department of Managed Health Care, go to HMO Reports.
All Provider Complaint Form submissions will be tracked for trends and emerging patterns of demonstrable and unjust payment patterns. Before the Department can commence a review, the provider is required to submit the dispute to the payor's Dispute Resolution Mechanism for a minimum of 45 working days or until receipt of the payor's written determination, whichever period is shorter.
Please complete this form in as much detail as possible to report your concern with a health care service plan (health plan) or one of the health plan's capitated providers who pay claims.
Appropriate supporting documentation is a prerequisite for a review of any issue. Upon submission of your complaint, an acknowledgement of the Department's receipt of your complaint will be e-mailed to you along with a complaint number, a list of the required supporting documentation and instructions for submitting the documentation.
The Department may forward any information submitted with a provider complaint form to the payor for a response.
The Department is often compelled to make hard choices in light of the resources available to it. Therefore, the Department reserves the right to identify priorities and to process complaints consistent with those priorities.
A Word about Reasonable and Customary Payment Complaints
The Knox-Keene Act’s Regulations, Title 28, Section 1300.71(a)(3)(B), require payors to reimburse non-contracted providers in an amount equal to the reasonable and customary value of the service. In the past several years the Department has seen a tremendous surge in complaints from non-contracted providers concerning reasonable and customary value payments by payors. The Department is not statutorily empowered to set rates for services.
The Department considers the fair reimbursement of providers a serious issue. Accordingly, in November 2009 the Department began an in depth data collection and study of the rates being paid in California. As of June 2010, the Provider Complaint Unit can no longer accept complaints which predominantly concern whether a payor’s reimbursement constitutes the usual, customary, and reasonable amount. The PCU will instead accept these complaints only for IDRP resolution.
