The Department of Managed Health Care (DMHC) regulates health care service plans that deliver health, dental, vision and mental health care benefits. Many of these health care service plans contract with Risk Bearing Organizations (RBOs) to deliver or manage health care services to consumers.
The DMHC recognizes that proper claims payment is essential to California's health care delivery system. In 2004, the DMHC established the Provider Complaint Section to ensure the prompt and accurate payment of claims to providers serving health plans under the DMHC’s jurisdiction.
This section provides answers to frequently asked questions about the claims payment and provider dispute requirements under the Knox Keene Act and the process for submitting a complaint about payors under the DMHC’s jurisdiction. Also included are useful terms.
Prescription Drug Prior Authorization or Step Therapy Exception Request Form (61-211)
Pursuant to Senate Bill 282 (2015) and Assembly Bill 374 (2015), the DMHC and the Department of Insurance developed a mandatory prescription drug prior authorization or step therapy exception request form. This form is to be used by providers when requesting a prescription drug prior authorization or step therapy exception. Providers should submit the necessary justification and clinical documentation supporting the provider’s determination as described in California Health and Safety Code section 1367.206.
Printable Notices
Plan Post-stabilization Authorization Contact Information (California Health and Safety Code sections 1262.8 and 1371.4)
Health plans that require prior authorization for post-stabilization care are required to submit to the DMHC specific contact information for noncontracting hospitals to use to obtain timely authorization for post-stabilization care. Below is a link containing a list of health plans that require prior authorization for post-stabilization care and their current contact information and telephone number(s). Health plans are required to update their contact information on an annual basis and as needed. Health plans that require prior authorization for post-stabilization care are also required to make this specific information available to non-contracting hospitals.
Patient Notices (California Health and Safety Code section 1262.8)
Noncontracting hospitals are required to provide a written notice to patients who refuse to consent to transfer to their health plan’s contracted hospital for post-stabilization health care services. The text of the notice is set forth in California Health and Safety Code section 1262.8(f). The notice warns patients that they will be financially responsible for any further care provided by the noncontracting hospital if they refuse to be transferred.
The Department has translated this patient notice into the threshold Medi-Cal languages and printable and downloadable versions are available for use by hospitals by clicking on the appropriate links below for each specified language. See Section 1262.8(f) for further information related to patient notices.
Plan Behavioral Health Crisis Post-Stabilization Authorization Telephone Number (California Health and Safety Code section 1374.724)
Health plans are required to prominently display on the health plan’s internet website the specific telephone number for noncontracting providers to obtain prompt authorization for the transfer of a stabilized enrollee's care to another provider or authorization to provide poststabilization care, ensure the telephone number published on the health plan’s internet website is the correct telephone number for such purposes, update the telephone number on the health plan's internet website within one business day if the telephone number changes, and provide the telephone number to the DMHC.
Pursuant to Assembly Bill 988 (2022) and Assembly Bill 118 (2023), the DMHC issued guidance via APL 25-006. This APL provides information regarding the obligations of health plans related to behavioral health crisis services provided to an enrollee by a 988 center or mobile crisis team. This guidance is also meant to aid providers in determining what enrollee information, CPT codes, and provider type are required in order to properly submit claims for commercial enrollees who receive mobile crisis services.
Community Assistance, Recovery, and Empowerment (CARE) Contact Information (California Health and Safety Code section 1374.723)
The link contains points of contact and phone numbers (it may be a voicemailbox or a person’s direct line) for County Behavioral Health Departments and/or providers to use to contact the health plan about claims for services that arise from a Community Assistance, Recovery, and Empowerment (CARE) agreement or CARE plan (CARE Services) or about an enrollee that is the subject of a pending CARE petition.