Provider Complaint Against a Plan

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 means of ensuring prompt payment.

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. 

Emergency Services Independent Dispute Resolution Process (EMTALA IDRP)

The DMHC established an Emergency Services Independent Dispute Resolution Process (IDRP) to afford non-contracted providers who deliver Emergency Medical Treatment & Active 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. The Emergency Services IDRP is voluntary and non-binding as to both providers and payors.

For more information regarding the Emergency Services IDRP and how to file a claim.

Non-Emergency Services Independent Dispute Resolution Process (AB 72 IDRP)

New legislation enacted in 2016 (AB 72) established the Non-Emergency Services IDRP. AB 72 protects consumers from surprise medical bills for non-emergency services rendered by non-contracting providers at contracted facilities on or after July 1, 2017. AB 72 also takes consumers out of any ongoing billing disputes by creating a binding IDRP to allow non-contracting providers and payors to dispute the appropriate reimbursement amount for non-emergency services. The Department has contracted with an independent dispute resolution organization for the AB 72 Non-Emergency Services IDRP, which began processing disputes on September 1, 2017.

For more information regarding the Non-Emergency Services IDRP and how to file a claim.