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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.
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IMR Information
Claim Issues
In January of 2001, AB 1455 (Chapter 827, Statutes of 2000) established new requirements for prompt payment of provider claims by health plans. This legislation, and the corresponding regulations, require the payment of interest, and in some cases penalties, for delayed payments. The legislation and regulations direct the DMHC to streamline provider claims-payment by establishing internal dispute resolution processes for payers (including both health care service plans and their capitated providers/RBOs). Health plans are required to submit a Quarterly Claims Settlement Practices Report, which contains information on whether the plan or any of its capitated providers failed to timely reimburse at least 95% of complete claims with the correct payment, including interest and penalties. If you'd like to view the report, please see the link below.
Provider Complaint System
The DMHC has developed a system of investigating and addressing unfair payment or billing patterns. As a result, an online Provider Complaint System was developed to evaluate claim reimbursement disputes If you are provider and would like to report a problem regarding claims payment, please complete an online Provider Complaint form.
For a single claim reimbursement dispute, please complete an Individual Provider Complaint form. For multiple "like" disputes, 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.
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, a list of the required supporting documentation and instructions for submitting the documentation.
To submit a provider complaint.
Independent Dispute Resolution Process (IDRP)
The DMHC has established an Independent Dispute Resolution Process (IDRP) to afford non-contracted providers of emergency hospital and physician services for HMO enrollees a fast, fair, and cost effective way to resolve claim payment disputes with health care service plans and their capitated providers (collectively referred to as "payers"). The IDRP is voluntary for both non-contracted providers and payers, and will provide a model for the DMHC to study and use as it begins to structure an eventual permanent dispute process.
The IDRP will employ a "baseball style" arbitration model, so called because major league baseball contract disputes are resolved by an arbitrator, with each side presenting what it feels is a reasonable salary, and the arbitrator then choosing one of the two salaries. This encourages the two parties to negotiate realistically, or risk having the other side's proposal accepted. For the IDRP, the provider's original billed amount and the payer's original paid amount will be used to determine which amount better reflects the reasonable and customary value of the services performed.
A hospital or institution may elect to submit an alternative amount that is willing to be accepted for the dispute claim(s). If the hospital or institution elects to submit an alternative amount then the payer may also submit an alternative amount that is willing to be paid for the disputed claim(s). These alternative amounts will then be used to determine which amount better reflects the reasonable and customary value of the services performed.
The Maximus Center for Health Dispute Resolution (CHDR) and Zaretsky and Associates have been selected by the DMHC to conduct independent reviews and render an impartial decision in provider payment disputes submitted to the program. CHDR, a nationally accredited health appeals organization, already serves more than 25 other states in the role of reviewer of appeals made by health plan enrollees, as well as performing reviews for the Federal Centers for Medicare and Medicaid Services. . Zaretsky & Associates is a Sacramento-based consulting firm with experience in Strategic Planning for Public and Private Health Systems, economic analysis, and market studies.
By submitting a claim dispute through the IDRP, the provider agrees to not invoice, balance bill, or otherwise seek to collect any payment from the health plan enrollee, except for applicable co-payments and deductibles.
A provider may submit an individual claim, or up to 50 substantially similar claims in a single filing, with a nominal filing fee based on the number of claims submitted per dispute. If the payer elects not to participate in the IDRP, the DMHC will return the provider's filing fee. Neither DMHC nor Maximus will publicly disclose any IDRP submissions or determinations that are specific to the participants, except to the participants themselves, or as required by law.
For a limited time, the Department is waiving fees for all physicians who submit a claim to IDRP.
For more information regarding the IDRP and how to file a dispute.
