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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 Department of Managed Health Care established an Independent Dispute Resolution Process (IDRP) to afford non-contracted providers who deliver 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.