Frequently Asked Questions

For Enrollees

I recently enrolled in a health plan through Covered California; can I file a complaint with the Department of Managed Health Care?

Yes. Currently, the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) regulate Covered California health plans. At this time, the DMHC regulates the vast majority of Covered California Health Plans. If you contact the DMHC and we find that your health plan is under the jurisdiction of CDI, we will forward your complaint to CDI.

What kinds of complaints does the Help Center handle?

The Consumer Complaint process assists consumers in resolving issues with their health plans. If you disagree with your health plan's decision, or it has been at least 30 days since you filed a complaint with your health plan, you can file a complaint with the DMHC. Most times, the DMHC will review and make a decision within 30 days from receipt of your complaint. However, due to the complexity of your complaint, the Consumer Complaint process could take longer than 30 days.

• You can’t get the medicine or treatment you need.
• You have to wait too long for a referral, authorization, test, or appointment.
• You are being sent home from the hospital too soon.
• You have a problem with a bill, claim, or co-pay.
• You received a bill for emergency or urgent care.
• You cannot get services in your language.
• Your doctor or hospital is no longer with your health plan.

What is an Independent Medical Review (IMR)?

If your health plan denies your request for medical services or treatment, you can file a complaint (grievance/appeal) with your health plan. If you disagree with your health plan's decision, or it has been at least 30 days since you filed a complaint with your health plan, you can request an IMR with the DMHC. The DMHC staff will determine whether your issue qualifies for an IMR.

An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service(s) or treatment(s) you need by requesting an IMR. Approximately 68%* of enrollees that submit IMR requests to the DMHC receive the service(s) or treatment(s) they requested. If the IMR is decided in your favor, your health plan must authorize the service(s) or treatment(s) you requested. An IMR is free to enrollees.

* This figure is based on information contained in the DMHC's 2022 Annual Report.

Can I have a friend or family member contact the DMHC on my behalf to obtain information about my Independent Medical Review or Consumer Complaint?

Yes. However, the DMHC must have on file a completed and signed DMHC Authorized Assistant Form. The DMHC cannot speak to anyone about your Independent Medical Review or Consumer Complaint unless we have your authorization to do so. Completion and submission of the DMHC Authorized Assistant Form tells the DMHC that it has your permission to speak with the person you have designated as your authorized assistant or representative.

Can I file a complaint with the DMHC on behalf of someone who is deceased?

Yes. However, the DMHC must have on file a completed and signed DMHC Legal Representative for Deceased Patient Form. The DMHC cannot speak to anyone about another person's Independent Medical Review or Consumer Complaint unless we have authorization to do so. Completion and submission of the DMHC Legal Representative for Deceased Patient Form tells the DMHC that you have the legal authority to make medical decisions on behalf of the deceased.

What documentation must be included with the Independent Medical Review or Consumer Complaint to file a complaint with the DMHC on behalf of someone who is deceased?

1. A completed and signed DMHC Legal Representative for Deceased Patient Form;
2. A copy of the deceased's death certificate; and
3. Documentation naming you the legal representative of the deceased (i.e., copy of a probate court order naming you as the executor/executrix of the estate, or documentation of guardian status if the deceased was a minor).

What requests qualify for an IMR?

A request will qualify for an IMR if your health plan:

• Denies, modifies, or delays a service or treatment because the health plan determines it is not medically necessary.
• Will not cover an experimental or investigational treatment.
• Will not pay for emergency or urgent medical services that you have already received.

What are my chances of getting a service that my health plan has denied?

In approximately 68%* of IMR cases, the health plan’s denial of service was reversed by the health plan or overturned by the Independent Medical Review Organization and the enrollee received authorization for the requested service or treatment. If the IMR decision is in your favor, the health plan must authorize the service(s) or treatment(s) within five business days. The IMR is free, and in most cases the IMR is decided within 30 days of IMR qualification and receipt of all required documentation. If you need more local, one-on-one assistance in filling out the IMR form, please contact the DMHC at 1-888-466-2219 or the DMHC’s Consumer Assistance Program, Health Consumer Alliance, at 1-888-804-3536.

* This figure is based on information contained in the DMHC's 2022 Annual Report.

Who is not eligible for an IMR?

• Medicare enrollees.
• Medi-Cal fee-for-service members (Medi-Cal members who are not in a managed care plan).
• Members of self-insured and self-funded plans.
• An enrollee disputing a workers' compensation claim.

What if my health plan says the service I want is not covered by my benefits?

Complete the Independent Medical Review Application/Complaint Form and submit online, by mail, email, or fax. The DMHC will review your Independent Medical Review Application/Complaint Form to decide if the service you want is a covered benefit. If the service is not covered, we will inform you that you do not qualify for an IMR and your complaint will be reviewed as a Consumer Complaint.

Can I get an IMR if my health plan will not pay for the medicine I think I need?

If your health plan covers prescription drugs but says that the drug you asked for is not medically necessary or is experimental or investigational, you may qualify for an IMR.

What happens if my problem does not qualify for an IMR?

The Help Center will send you a letter informing you that your problem does not qualify for an IMR. If this happens, the Help Center will review your case through its Consumer Complaint process and send you a written decision within 30 days. You do not need to send in another form.

How long does an IMR take?

• If your health problem is urgent, an IMR is usually decided within 7 days after we receive the supporting documentation from you, the doctor, and the health plan. This is called an expedited IMR. A health problem is urgent if it is a serious and immediate threat to your health. Your doctor must send us written documentation that your health problem is urgent.
• If your health problem is not urgent, an IMR is usually decided within 45 days after we receive the supporting documentation from you, the doctor, and the health plan.
• An IMR can take longer if we do not receive all of the medical records we need from you or your treating doctor. If you are seeing a doctor who is not in your health plan's network, it is important that you obtain and send us your medical records from that doctor. Your health plan is required to get copies of your medical records from doctors who are in the network.

What happens if the IMR is decided in my favor?

If the IMR is decided in your favor, your health plan must authorize the service or treatment.

Will my medical condition and treatment stay private?

Yes. Your name, medical records, and all other personal medical information are kept private and confidential under California law. IMR decisions are public, but they do not disclose the names of any patients, doctors, or facilities.

Where can I read the IMR laws?

They are located in sections 1374.30 and 1370.4 of the Knox-Keene Health Care Service Plan Act of 1975 (part of the California Health and Safety Code). You can also see the rules that the DMHC created for the IMR process. They are located in Title 28 of the California Code of Regulations, sections 1300.74.30 and 1300.70.4. Click this link to review health care laws.

Do you need more assistance in filing a grievance with your health plan?

The Department of Managed Health Care contracts with the Health Consumer Alliance, a group of local, community-based organizations that will provide you with assistance filing a grievance with your health plan. If you need one-on-one assistance, please contact the Health Consumer Alliance’s Consumer Assistance Program at 1-888-804-3536.

What does it mean if my health plan says a service is not medically necessary?

It means your health plan believes the service you or your doctor requested is not appropriate for your medical condition, or your health plan wants you to try a different treatment instead. Sometimes doctors and health plans do not agree on what is medically necessary.

Ask your doctor or your health plan to put the reason you cannot get the treatment in writing. If you disagree, you can file a complaint with your health plan. If your health problem is urgent, meaning it is a serious threat to your health, ask your health plan for an expedited review. If your health plan determines your condition is urgent, your health plan must give you a decision within 3 days. If you disagree with your health plan's decision, contact the Help Center.

What happens if my health plan, my doctor, or other hospital staff informs me my health plan will no longer pay for me to remain in the hospital?

Call your health plan to appeal the decision, and ask for an expedited review. You can stay in the hospital until your review is completed. However, you may be responsible for the bill if your health plan’s appeal decision denies continued payment for medical treatment in the hospital. Your health plan must give you a decision within 3 days, or sooner if needed. You should also call the Help Center and state that your problem is urgent if your health plan does not expedite your appeal review or the appeal decision denies continued payment for medical treatment in the hospital and you want the Department to decide if your continued treatment in the hospital should be covered. If you are in a Medicare Advantage plan, visit Livanta's website or call 1-877-588-1123. If you are in a Medi-Cal managed care plan, call 1-888-452-8609.

What if I got a bill for care that I received?

Usually a doctor, hospital, or other provider in your health plan's network can bill you only for your deductible, co-pay, or co-insurance. If you receive a bill for additional costs, call the billing office that sent you the bill and ask them to explain the bill to you. If you disagree, file a complaint with your health plan. If you are not satisfied with your health plan's decision, contact the Help Center.

I got a bill for emergency care that I received, but I thought it was covered.

Your health plan must cover emergency care. If your health plan does not pay the bill, file a complaint with your health plan. If you are not satisfied with your health plan's decision, contact the Help Center.

I think I received poor care.

You can contact your health plan to file a complaint. If you are not satisfied with your health plan's response, you can contact the Help Center.

What happens if my doctor (or hospital) is no longer in my health plan's network?

You will need to change to a new doctor (or hospital) that is in your health plan's network. Contact your health plan for a list of in-network doctors or hospitals. You should ask your previous doctor to send your medical records to your new doctor. In some cases, you can continue with your doctor or hospital for an extended period of time.

What can I do if I lost my job and my health plan coverage?

You have the option of keeping your health plan coverage until you enroll into a new health plan through a new job. Enroll in Federal COBRA/Cal-COBRA or an individual plan as soon as you can. You have 60 days of being notified of your Federal Cobra/CAL-COBRA rights to enroll. You may also contact Covered California toll free at 1-800 300-1506 for health care coverage options.

My health plan is canceling my coverage.

• Your health plan may cancel your coverage if you or your employer did not pay your premiums. If this happens, call your health plan right away to discuss and/or make payment arrangements.
• Your health plan can also cancel coverage if you were deceptive or fraudulent when obtaining services or violated the contract in other ways.
• Your coverage may also end because your employer stops offering health coverage to employees. For information on continuing your coverage, read about HIPAA and Conversion Plans. For information about health care coverage options, please contact Covered California.
• If you think your coverage was canceled because of your health condition or because you need medical care, contact the Help Center.

For Providers

What should I do if I have a problem getting paid by a payor?

The Knox-Keene Act and its implementing Regulations require each health care service plan to provide "a fast, fair and cost-effective dispute resolution mechanism under which providers may submit disputes to the plan." You are required to first try to resolve your concern directly with the health care service plan through its Provider Dispute Resolution mechanism. If you disagree with the payor's dispute resolution response, or if the payor fails to respond to your dispute within 45 working days, you may submit a provider complaint through the DMHC website.

What if I have a problem with a medical group?

You may report problems with a medical group using the methods described above if the medical group is the payor.

What is the Department doing to resolve problems with providers not getting paid?

The DMHC reviews all complaints submitted by providers regarding problems with health plans and payors. We look for patterns or systemic problems and address them with individual health plans or payors through a number of oversight tools, including financial audits and medical surveys. Additionally, the DMHC can take enforcement action against health plans found to violate the law. To date, the DMHC Provider Complaint Section& has recovered more than $125,000,000 in payments to providers.

What does the review process consist of?

An initial review is performed on all electronically filed provider complaints. This review is based on the information provided within each complaint form. Data provided in these forms will be analyzed to look for evidence of "unfair payment patterns." It will also be used to identify common types of payment issues. This data will provide the basis for DMHC investigations and potential actions to address unfair payment patterns.

Further review of a provider complaint may be initiated based on available resources and consistent with DMHC priorities. This process will require a verification of the facts presented in the electronically filed complaint by comparing it with backup documentation. When further review of a complaint has been initiated, the DMHC will open a case file and will request the provider to submit additional backup documentation relevant to the case.

Upon receipt of the documentation, the DMHC may determine whether there is non-compliance with the provisions of the Knox-Keene Act and its Regulations.

What do I need to do to file a complaint with the DMHC?

Before you file a complaint with the DMHC, you should submit a request for dispute resolution through your payor's Provider Dispute Resolution mechanism. Then, if you disagree with the response, complete and submit an electronic Provider Complaint Application with the DMHC.

Is the Provider Complaint process in place of taking legal action?

The DMHC's Provider Complaint process does not take the place of a civil action or other available legal remedies. We cannot give legal advice or act as your attorney. The complaint process should not be considered a way to gather facts in preparation for any potential legal action. You can take legal action at any time during the complaint process. In the event that the claims comprising your complaint are in litigation, the DMHC may at its discretion suspend or delay its investigation until the civil adjudication of those claims has been completed.

What qualifies as a multiple "like" complaint?

Multiple "like" complaints are for the same or similar services, involving the same provider, and against the same health plan and payor of services. For "like" complaints, the payor's actions giving rise to the dispute would be the same for each complaint. For example:

• Payor fails to correctly pay claims for the same or very similar CPT codes or health care services;
• Payor fails to correctly pay interest on claims where interest is owed;
• Payor requests unnecessary documentation prior to paying claims for the same or very similar CPT codes or health care services;
• Payor is otherwise engaged in the same unjust payment pattern, such as those set forth in California Code of Regulations, title 28, section 1300.71 (a)(8)(A)-(V).

Legal Action Questions

Does the Help Center act as my attorney?

No. The Help Center does not give legal advice or act as your attorney. We will review your issue through our IMR or Consumer Complaint process and let you know if your health plan must provide the service or item you are requesting.

How will my complaint be decided?

Your IMR will be decided by qualified, independent clinicians who are not employed by your health plan. Your complaint will be decided by experienced analysts, nurse consultants, or lawyers. The Help Center will send you and your health plan a letter that explains our decision. If the complaint is decided in your favor, we will require your health plan to provide or pay for the service, or do whatever is needed to resolve the complaint. If the complaint is not decided in your favor, you cannot appeal the decision. However, you may still be able to take legal action and may want to speak with a private attorney.