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Provider Complaint Against a Plan

Provider Complaint Against a Plan

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 primary means of ensuring prompt payment.

Before the DMHC can begin a review, the provider is required to submit the dispute to the payer's Dispute Resolution Mechanism for a minimum of 45 working days or until receipt of the payer's written determination, whichever period is shorter.

Appropriate supporting documentation is a prerequisite for a review of any issue. Upon submission of your complaint, 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.

How to submit a provider complaint Submit a Provider Complaint

Toll-free provider complaint line: 1-877-525-1295

About the Provider Complaint Process

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.

Independent Dispute Resolution Process (IDRP)

The DMHC established an Independent Dispute Resolution Process (IDRP) to afford non-contracted providers who deliver Emergency Medical Treatment & Labor Act (EMTALA) required emergency services a fast, fair and cost-effective way to resolve claim payment disputes with health care service plans or capitated providers concerning the “reasonable and customary” value of services rendered. IDRP is voluntary and non-binding as to both providers and payers.

For more information regarding the Independent Dispute Resolution Process (IDRP) and how to file a claim.