Part 3: Insurance Company Complaints

Welcome to part 3 of of our 3-part series on filing insurance company complaints.

Part 1: Overview
Part 2: California Health Plan Complaint Process
Part 3: Filing a Complaint with the California Department of Insurance (below)

FILING A COMPLAINT WITH THE DEPARTMENT OF INSURANCE

Before You Submit a Provider Complaint
Before you file a complaint with the CDI, you must first submit the dispute to the insurer's Dispute Resolution Mechanism. Under the Dispute Resolution Mechanism process, disputes must be submitted to the insurer in writing and include the following information: provider name, provider tax identification number, patient name, insurer's identification information, dates of service, description of dispute, and if applicable, billed and paid amounts.

Insurers must provide the procedures for submitting a dispute through the Dispute Resolution Mechanism, including the location and telephone number where information regarding disputes may be submitted. Insurers must also ensure that a Dispute Resolution Mechanism is accessible to non-contracting providers for the purpose of resolving billing and claims disputes. Insurers are required to resolve each dispute and issue a written determination within 45 working days of the receipt of the provider's dispute.

Filing A Complaint with the CDI
Once you have determined that the plan is regulated by the CDI and have submitted a dispute to the insurer for review under the Dispute Resolution Mechanism process, and you disagree with the decision or would like the CDI to review an issue, you may submit a complaint by completing a Health Care Provider Request for Assistance (HPRFA). To ensure proper review of the case, the following documents should be sent to the Department:

• A copy of the completed Health Care Provider Request for Assistance Form.
• Copy of the patient's Assignment of Benefits documentation.
• Copy of claim forms submitted to the insurance company.
• Copies of all correspondence between the provider and the insurance company, including all related Explanation of Benefits (EOB).
• Copy of the Dispute Resolution Mechanism process determination letter.
• Copy of the patient's insurance identification card.
• Copy of the provider's contract with the insurance company, if any.

Examples of the types of problems you can submit to the CDI:

• Improper denial or delay in payment of a claim
• Other claims handling issues
• Dispute Resolution Mechanism difficulties
• Misconduct of the health insurer

Examples of complaints that do not fall within the jurisdiction of the CDI

• Workers Compensation Claims
• Knox-Keene Health Care Service Plans
• Medi-Cal
• Medicare
• Self-funded Employee Benefit Plans

You may submit a complaint to the Department of Insurance by completing a Health Care Provider Request for Assistance (HPRFA) for each claim submitted to the insurer. You may request a HPRFA to be mailed to you by calling the Consumer Hotline toll-free number (800) 927-HELP (4357). You may also download the HPRFA by visiting www.insurance.ca.gov.