Department of managed health care - State of California

Did you know the State of California has an information website? I know sometimes we get overloaded with resources and it becomes a major decision on where to go and how much time we can devote to research. Resources on the page are for both consumers and providers. BD

Consumer protection is the DMHC's top priority. We make sure that health plans follow California managed care laws and remain financially stable.

One item in particular that might be helpful is the HMO Help Center. There are levels for elevation if a claim solution has not been provided by the insurance carrier. The site recommends a complaint first be addressed with the insurance carrier before elevating to this level. BD

HMO Help Center
Call 1-888-HMO-2219 (1-888-466-2219)
TDD: 1-877-688-9891
There is no charge for your call.
The HMO Help Center is open 24 hours a day, 7 days a week.
The HMO Help Center can provide help in many languages.

You Can Apply for an IMR (independent Medical Review) if Your Health Plan:

Denies, changes, or delays a service or treatment because the plan determines it is not medically necessary.
Will not cover an experimental or investigational treatment for a serious medical condition.
Will not pay for emergency or urgent medical services that you have already received.

Before You Apply

In most cases, you must complete your health plan's complaint process before you apply for an IMR. Your plan must give you a decision within 30 days or within 3 days if your problem is an immediate and serious threat to your health.

Source: http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_complaint.asp

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.

Provider Line: 1-877-525-1295

Source: http://www.dmhc.ca.gov/providers/clm/clm_default.asp