The Department of Managed Health Care (DMHC) has established an Emergency Services Independent Dispute Resolution Process (IDRP), a fast, fair and cost-effective way to resolve claim payment disputes.
Participation in the Emergency Services IDRP is voluntary and, while the process is non-binding, DMHC feels that IDRP decisions may offer providers and payers a fast, fair and cost-effective alternative to other slower and more costly legal remedies. As such, the parties are encouraged to comply with the decision issued by the Emergency Services IDRP External Reviewer.
Do I Qualify?
Non-contracted providers who deliver EMTALA-required emergency services (“providers”) working with health care service plans or capitated providers (“payers”) are eligible to submit a IDRP concerning the “reasonable and customary” value of services rendered.
A provider may request review through the IDRP for an individual claim or for multiple claims (up to a total of 50 substantially similar claims.)
If you are a provider but these parameters don’t apply to you, see how you can file a Complaint Against A Plan.
Eligible claim disputes are those disputes that are subject to DMHC jurisdiction and meet each of the following four criteria:
- The disputed claim is limited to emergency services rendered by non-contracted physicians or hospitals.
- The services were rendered within the last four years.
- The dispute is limited to disagreement concerning the reasonable and customary value of the services rendered.
- The provider has completed the payer’s dispute resolution process.
Disputes concerning claims that have not been submitted to the payer’s dispute resolution process.
- Disputes concerning claims that are currently in arbitration or litigation in state or federal court.
- Late payment disputes.
- Interest payment disputes.
- Medi-Cal program claim disputes for which the State of California’s “Fair Hearing Process” has commenced.
- Claim disputes that are not subject to DMHC jurisdiction.
- Claim disputes with health plans licensed or regulated by another state.
- Disputes regarding claims that do not involve covered benefits.
- Claims denied on the basis that the services were not medically necessary or were experimental/investigational in nature.
Steps for Filing
Upon receipt of the provider’s request, the DMHC will review the provider’s submission and then contact the payer to confirm their willingness to participate in the Emergency Services IDRP with regard to the disputed claim. If the payer declines to participate, the provider will be notified. If the payer elects to participate, information concerning the claims dispute is forwarded to the Emergency Services IDRP External Reviewer, who may request further documentation or information, as needed. (Except as required by law, documentation and information submitted to DMHC regarding disputed claims considered through the Emergency Services IDRP will remain confidential.)
Ordinarily, an Emergency Services IDRP decision will be issued within sixty (60) days of receipt of required provider and payer documentation.
About the Decision Process
The Emergency Services IDRP utilizes a decision process that is similar to the "baseball style" model of arbitration. Accordingly, the Emergency Services IDRP External Reviewer is required to decide which figure (either the provider’s billed amount, or the payer’s paid amount) is most representative of the reasonable and customary value of the emergency services that were rendered. The Emergency Services IDRP External Reviewer cannot “split the difference” or choose a different amount (outside of those submitted by one of the parties). Note: Under the Emergency Services IDRP, a hospital provider may elect to lower its billed amount in connection with the hospital’s Emergency Services IDRP submission.
Complaint Fee Schedule
Currently, there is no Emergency Services IDRP complaint filing fee for individual physicians. For hospital providers, the number of disputed claims listed on the Emergency Services IDRP Request Form determines the filing fee. Substantially similar claims can be aggregated up to fifty (50) in a single Emergency Services IDRP Request Form. "Substantially similar" claims are those that involve the same or similar services and the same payer. Fees are subject to change without notice.
1 individual claim - $100.00
2 to 10 claims - $200.00
11 to 25 claims - $400.00
26 to 50 claims - $600.00