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 means of ensuring prompt payment.
Before You Submit a Complaint
Before the DMHC conducts a review, the provider is required to submit the dispute to the payor's Provider Dispute Resolution (PDR) mechanism for a minimum of 45 working days or until receipt of the payor's written determination, whichever period is shorter.
Upon submission, it is the responsibility of the initiating party to submit documentation that supports their position. Documentation should be free from Protected Health Information (PHI) of patients not associated with the complaint; it is the initiating party’s responsibility to redact any PHI prior to submission. If the Department requires additional information, a request will be sent to the initiating party, documentation must be submitted to the Department within five (5) working days. The Department may close a provider complaint in the event the provider fails to timely submit copies of all required documents. Upon submission, you will receive an acknowledgement e-mail with your complaint's unique identification number.
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.
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.
Types of Provider Complaints
- Individual Complaints
- Multiple Complaints (up to 25 claims per complaint)
- Emergency Services Independent Dispute Resolution Process (IDRP)
- Non-Emergency Services Independent Dispute Resolution Process (AB72 IDRP)
Does My Complaint Qualify?
Eligible Claims
- The services were rendered within the last four years.
- Provider Dispute Resolution (PDR) has been filed through the responsible payor's Provider Dispute Resolution mechanism and you have received a written determination or the appeal has been pending within that process for more that 45 working days.
- The claim dispute is with a health plan, medical group, or Independent Physicians' Association (IPA) that is contracted with a health plan licensed under the Knox-Keene Act. A list of all Knox-Keene Act licensees is available for your review.
Ineligible Claims
- The services were rendered beyond the last four years.
- Provider Dispute Resolution (PDR) has not been filed through the responsible payor's Provider Dispute Resolution mechanism or the appeal has not been pending for more than 45 working days.
- The claim dispute is with a health plan, medical group, or Independent Physicians' Association (IPA) that is contracted with a health plan not licensed under the Knox-Keene Act. A list of all Knox-Keene Act licensees is available for your review.
- The claim dispute is with a health plan licensed or regulated by another state.
Department Jurisdiction
The DMHC is only able to review complaints against Knox-Keene Act licensees. The Department does not have jurisdiction over the following plans or products:
- Most PPO Plans
- Self-Funded Plans
- Blue Cross Life and Health Products
- Medicare Managed Health Plans
For more information about the complaint process, please review our FAQ.
Need Assistance? Call the Provider Complaint line toll-free at 1-877-525-1295.
Provider Complaint Statistics
The Department'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.