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Submit a Provider Complaint

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. The following is intended to provide information and assistance:

Submit a Provider Complaint 


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

Before You Submit a Complaint

All complaints submitted regarding claims must have a date of medical services rendered no more than four years prior to the date of the complaint submission.

To be eligible for a case review, your complaint must have been reviewed by the Payor's Provider Dispute Resolution process, or it must have been pending within that process for more than 45 working days. If you submit a complaint to the DMHC prior to participating in the Payor’s Provider Dispute Resolution process, your complaint will be closed without review.

Prior to filing your complaint with the DMHC, please determine if your complaint is against a health plan (or a Medical Group or IPA that is contracted with a health plan) licensed under the Knox-Keene Act. A list of all licensees is available for your review. We are only able to review complaints against Knox-Keene licensees. Please verify that your complaint concerns one of these health plans. With the exception of certain Blue Cross of California and Blue Shield of California products, the DMHC does not have jurisdiction over most PPO plans. The DMHC does not have jurisdiction over self-funded plans even though a self-funded plan  may be administered by a Knox-Keene licensee.

The DMHC does not have jurisdiction over Blue Cross Life and Health products. Blue Cross Life and Health products are regulated by the California Department of Insurance. Please see the Department of Insurance regarding complaints about Blue Cross Life and Health.

 

The DMHC is unable to review complaints against Medicare Managed Health Plans. Complaints against Medicare Managed Health Plans should be submitted to the Centers for Medicare and Medicaid Services (CMS).

Review of provider complaints is limited based on staffing available to conduct these reviews. When a case review has been initiated, the DMHC will open a case file and will request the provider to submit relevant documentation. Upon receipt of the documentation, the DMHC will determine whether there is non-compliance with the provisions of the Knox-Keene Act. In many instances, a case review will make a determination of whether claims should have been paid, or whether interest is due. In-depth analysis of the results of case reviews will also supplement the findings of Emerging Trend Analysis.

Using the Provider Complaint form

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 DMHC to commence a substantive review, which may identify system patterns or problems with particular health plans or capitated providers.

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 DMHC'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 DMHC may forward any information submitted with a provider complaint form to the payor for a response.

If you have already filed a complaint that was accepted for case review, and you have been contacted to submit additional information for consideration, please mail or fax the documents along with a copy of the original case Confirmation Receipt or letter that includes the assigned case/complaint number. These materials can be mailed or faxed to:

Department of Managed Health Care
Provider Complaint Unit
980 9th Street, Suite 500
Sacramento, CA 95814
(877) 525-1295
(916) 255-2282 Fax
pcu@dmhc.ca.gov

 

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 DMHC has seen an increase in complaints from non-contracted providers concerning reasonable and customary value payments by payors. Please note, the DMHC is not statutorily empowered to set rates for services.

The DMHC considers the fair reimbursement of providers a serious issue. Accordingly, in November 2009 the DMHC began an in depth data collection and study of the rates being paid in California. As of June 2010, the Provider Complaint Unit (PCU) 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.

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

Provider Complaint / Dispute Issues Statistics

The Department of Managed Health Care's Provider Complaint Unit tracks and trends provider complaints submitted by California providers. The posted statistical information reflects the provider complaint activity for each calendar year quarter.

2015 Provider Complaint / Dispute Issues Statistics

2014 Provider Complaint / Dispute Issues Statistics

2013 Provider Complaint / Dispute Issues Statistics

2012 Provider Complaint / Dispute Issues Statistics

2011 Provider Complaint / Dispute Issues Statistics

2010 Provider Complaint / Dispute Issues Statistics

2009 Provider Complaint / Dispute Issues Statistics

2008 Provider Complaint / Dispute Issues Statistics