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Frequently Asked Questions

For Enrollees

I recently enrolled in a health plan through Covered California; can I file a complaint with the Department of Managed Health Care?

Yes. Currently, the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) regulate Covered California health plans. At this time the DMHC regulates the vast majority of Covered California Health Plans. If you contact the DMHC and we find that your health plan is under the jurisdiction of CDI, we will help you contact the CDI.

What is a Consumer Complaint?

The Consumer Complaint process assists consumers in resolving issues with their health plans, including the following types of complaints:

  • Improper denial or delay in settlement of a claim.
  • Health claims that have been denied by the health plan because the service or treatment is not covered under the contract.
  • Legal interpretations of policy language, provisions, and terms.
  • Bad faith allegations and other demands for extra payments under the health insurance contract.
  • Alleged illegal cancellation or termination of a policy.
  • Alleged misrepresentation by an agent, broker, or solicitor.
  • Alleged theft of premiums paid to an agent, broker, or solicitor.
  • Issues with providers, medical groups and pharmacies.

What is an Independent Medical Review (IMR)?

An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service(s) or treatment(s) you need by requesting an IMR. Approximately 60% of enrollee’s that submit IMR requests to the DMHC receive the service(s) or treatment(s) they requested. If the IMR is decided in your favor, your plan must authorize the service(s) or treatment(s) you requested. IMR’s are free to enrollees.

If your health plan denies your request for medical services or treatment, you can file a complaint (grievance/appeal) with your plan. If you disagree with your plan's decision, or it has been at least 30 days since you filed a complaint with your health plan you can request an IMR with the DMHC. The DMHC staff will determine whether your issue qualifies for an IMR.

Can I have a friend or family member contact the DMHC on my behalf to obtain information about my Independent Medical Review or Consumer Complaint?

Yes. However, the DMHC must have on file a completed and signed DMHC Authorized Assistant Form. The DMHC cannot speak to anyone about your Independent Medical Review or Consumer Complaint unless we have your authorization to do so. Completion and submission of the DMHC Authorized Assistant Form tells the DMHC that it has your permission to speak with the person you have designated as your authorized assistant or representative.

What requests qualify for an IMR?

A request will qualify for an IMR if your Health Plan:

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

What are my chances of getting a service that my health plan has denied?


If your health plan denies treatment apply for an Independent Medical Review (IMR), 60% of enrollees receive requested treatment through IMR.

In approximately 60% of IMR cases, the health plan’s denial of service was reversed by the health plan or overturned by the Independent Medical Review Organization and the enrollee received authorization for the requested service or treatment. If the IMR decision is in your favor, the health plan must authorize the service(s) or treatment(s) within five business days. The IMR is free, easy, and fast and in most cases, the IMR is decided within 30 days of IMR qualification and receipt of all required documentation. If you need more local, one-on-one assistance in filling out the IMR form, please contact the DMHC at 1-888-466-2219 or the DMHC’s Consumer Assistance Program, Health Consumer Alliance, at 1-888-804-3536.

Who is not eligible for an IMR?

Medicare enrollees.

Medi-Cal fee-for-service members (Medi-Cal members who are not in a managed care plan).

Members of self-insured, self-funded, and ERISA plans.

An enrollee that is disputing a worker’s compensation claim.

What if my plan says the service I want is not covered in my benefit package?

Complete and submit the Independent Medical Review Application/Complaint Form online by mail or fax. The DMHC will review your Independent Medical Review Application/Complaint Form to decide if the service you want is a covered benefit. If the service is not covered, we will inform you that you do not qualify for an IMR and your complaint will be reviewed as a Consumer Complaint.

Can I get an IMR if my plan will not pay for the medicine I think I need?

If your plan covers prescription drugs and it says that the drug you asked for is not medically necessary or is experimental or investigational, you may qualify for an IMR.

What happens if my problem does not qualify for an IMR?

The Help Center will send you a letter saying that your problem does not qualify. If this happens, the Help Center will review your case through its Consumer Complaint process and send you a written decision within 30 days. You do not need to send in another form.

How long does an IMR take?

  • If your health problem is urgent an IMR is usually decided within 7 days after the request qualifies for an IMR and the required documentation has been received by the DMHC’s Independent Medical Review Organization. This is called an expedited IMR. A health problem is urgent if it is a serious and immediate threat to your health. Your doctor must send us written documentation that your health problem is urgent.
  • If your health problem is not urgent, an IMR is usually decided within 30 days after we receive the supporting documentation from you, the doctor and the health plan.
  • An IMR can take longer if we do not receive all of the medical records that we need from you or your treating doctor. If you are seeing a doctor who is not in your health plan's network, it is important that you send us your medical records from that doctor. Your health plan is required to get copies of your medical records from doctors who are in the network.

What happens if the IMR is decided in my favor?

If the IMR is decided in your favor, your health plan must authorize the service or treatment.

Will my medical condition and treatment stay private?

Yes. Your name, medical records, and all other personal medical information are kept private and confidential under California law. IMR decisions are public, but they do not show the names of any patients, doctors, or facilities.

Where can I read the IMR laws?

See sections 1374.30 and 1370.4 of the Knox-Keene Health Care Service Plan Act of 1975 (part of the California Health and Safety Code). You can also see the rules that the DMHC has created for the IMR process. They are in Title 28 of the California Code of Regulations in sections 1300.74.30 and 1300.70.4. Click this link to review health care laws.

Do you need more assistance in filing a grievance with your health plan?

The Department of Managed Health Care contracts with the Health Consumer Alliance, a group of local, community-based organizations that will give you free help with filing a grievance with your health plan. If you need more local, one-on-one assistance, please contact the Health Consumer Alliance’s Consumer Assistance Program at 1-888-804-3536.

What does it mean if my health plan says a service is not medically necessary?

It means that your plan believes that the service you or your doctor requested is not appropriate for your medical condition, or the plan wants you to try a different treatment. Sometimes doctors and health plans do not agree on what is medically necessary.

Ask your doctor or your health plan to put the reason you cannot get the treatment in writing. If you disagree, you can file a complaint with your plan. If your health problem is urgent, meaning it is a serious threat to your health, ask the health plan for an expedited review. If your health plan determines your condition is urgent, your health plan must give you a decision in 3 days. If you disagree with your plan's decision, contact the Help Center.

What happens if I get sent home (discharged) from the hospital too soon?

Call your health plan and ask for an expedited review. You can stay in the hospital until your review is completed. However, you may have to pay the bill if the review is in the plan's favor. Your plan must give you a decision within 3 days, or sooner if needed. You should also call the Help Center and say your problem is urgent. If you are in a Medicare Advantage plan, contact Livanta at 1-877-588-1123. If you are in a Medi-Cal managed care plan, call the Medi-Cal Ombudsman at 1-888-452-8609.

What if I got a bill for care that I received?

Usually, a doctor, hospital, or other provider in your health plan's network can bill you only for your deductible, co-pay, or co-insurance. If you get a bill for another cost, call the billing office that sent you the bill and ask them to explain the bill to you. If you disagree, file a complaint with your plan. If you are not satisfied with your plan's decision, contact the Help Center.

I got a bill for emergency care that I received, but I thought it was covered?

Your health plan must cover emergency care wherever you receive it. If your plan does not pay the bill, file a complaint with your health plan. If you are not satisfied with your plan's decision, contact the Help Center.

I think I received poor care.

Call your health plan and explain the problem. You can file a complaint with your health plan. If you are not satisfied with your plan's decision, you can contact the Help Center. You can also complain to the licensing agency that oversees the provider who gave you the care.

What happens if my doctor (or hospital) is no longer with my health plan?

You will need to change to a new doctor (or hospital) that is in your health plan. Contact your health plan for a list of doctors or hospitals. You should ask your old doctor to send your medical records to your new doctor. In some cases, you can continue with your same doctor or hospital for some time.

What can I do if I lost my job and my health plan coverage?

Try to keep your old health plan until you get a new health plan through a new job. Enroll in Federal COBRA/Cal-COBRA or an individual plan as soon as you can. You usually have to enroll within 60 days of being notified of your Federal Cobra/CAL-COBRA rights. You may also contact Covered California toll free at 1-800 300-1506 for health care coverage options.

My health plan is cancelling my coverage.

  • Your health plan may cancel your coverage if you or your employer did not pay your premiums. If this happens, call your plan right away and try to arrange payment.
  • A health plan can also cancel coverage if the member used fraud and deception to get services or violated the contract in other ways.
  • Your coverage may also end because your employer stops offering health coverage to employees. For information on continuing your coverage, read about HIPAA and Conversion Plans. For information about health care options, please contact Covered California
  • If you think your coverage was cancelled because of your health condition or because you need medical care, contact the Help Center.

For Providers

What should I do if I have a problem getting paid by a payor?

The Knox-Keene Act and its implementing Regulations require each Health Care Service Plan to provide "a fast, fair and cost-effective dispute resolution mechanism under which providers may submit disputes to the plan." You should always first try to resolve your concern directly with the Health Care Service Plan, through its Provider Dispute Resolution mechanism. If you disagree with the payor's dispute resolution response, you may submit a complaint through the DMHC website.

What if I have a problem with a medical group?

You may report problems with a medical group using the methods described above, if the medical group is the payor. If you report a problem regarding a medical group, we will monitor the organization directly and through the health plans with which it contracts.

What is the department doing to resolve some of these problems with providers not getting paid?

The DMHC monitors all complaints submitted by providers regarding problems with health plans and payors. We look for patterns or systemic problems and address them with individual health plans or payors through a number of oversight tools, including financial audits and medical surveys. Additionally, the DMHC can and will take enforcement action against health plans found to violate the law. To date the Provider Complaint unit has recovered more than $38,000,000 in reimbursements for providers.

What does the review process consist of?

An Initial Review will be performed on all electronically filed provider complaints. This review will be based on the information provided within each complaint form filed. Data provided in these forms will be rigorously analyzed to look for evidence of payor "unfair payment patterns." It will also be used to identify prevalent types of payment or contract issues. This data will provide the basis of targeted DMHC investigations, and potential actions to eliminate unfair payment patterns.

A Case Review of provider complaints may be limited, based on staff resources available, consistent with the DMHC priorities. This process will require a verification of the facts presented in an electronically filed complaint by comparing it with backup documentation. When substantive review of a complaint has been initiated, the DMHC will open a case file and will request the provider to submit backup documentation relative to the case.

Upon receipt of the documentation, the DMHC will determine whether there is non-compliance with the provisions of the Knox-Keene Act, and its Regulations. In many instances, substantive review will make a determination of whether claims should have been paid, or whether interest is due. Trend analysis of the results of substantive review will also supplement the findings of the initial review process, to ensure timely and accurate claims payment.

What do I need to do to file a complaint with the Department Of Managed Health Care?

Before you file a complaint with the DMHC, you should submit a request for dispute resolution through your payor's dispute mechanism. Then, if you disagree with the response, complete and submit a Provider Complaint Form with the DMHC.

Is this Provider Complaint process in place of taking legal action?

The DMHC's Provider Complaint process does not take the place of a civil action. We cannot give legal advice or act as your attorney. The complaint process should not be considered a way to gather facts in preparation for any potential legal action. You can take legal action at any time during the complaint process. In the event that the claims comprising your complaint are in litigation the DMHC may, at its discretion, suspend or delay its investigation until the civil adjudication of those claims has been completed.

What qualifies as a "like" multiple complaint?

"Like" complaints are ones where the issues are the same or very similar. For "like" complaints, the Payor's actions giving rise to the complaints would be the same or very similar for each complaint. For example:

  • Payor fails to correctly pay claims for the same or very similar CPT codes or health care services;
  • Payor fails to correctly pay interest on claims where interest is owed;
  • Payor requests unnecessary documentation prior to paying claims for the same or very similar CPT codes or health care services;
  • Payor violates the same provision of the applicable contract in regards to the payment of each claim;
  • Payor is otherwise engaged in any other unjust payment pattern, such as those set forth in Title 28, California Code of Regulations section 1300.71 (a)(8)(A)-(T).

Licensing & Reporting

How do I know if I need to be licensed by the Department of Managed Health Care?

Your first step is to review the laws and regulations that pertain to licensure. This information is available in the Knox Keene Act (Health and Safety Code § 1340, et seq.) and Title 28 of the California Code of Regulations (CCR).  You may wish to seek outside counsel to assist with the requirements.
Specific sections include: Health and Safety Code § 1345(f)(1), and §§ 1349 through 1356.1 and California Code of Regulations, Title 28, §§ 1300.51 through 1300.51.3.

Where can I find the Knox Keene Act and California Code of Regulations?

Laws and regulations relating to health care service plans in California are available by clicking the following link: Laws. The following specific sections pertain to licensure Health & Safety Code § 1345(f)(1), and §§ 1349 through 1356.1; California Code of Regulations, Title 28, §§ 1300.51 through 1300.51.3.  You may also purchase a hardcopy of the law for $14.50 by calling 916-324-8176.

How much does it cost to get licensed?

The cost can vary, however, the amount is not to exceed twenty-five thousand dollars ($25,000). See section 1356 of the Health and Safety Code pertaining to fees.

Who do I talk to if I have questions?

If, after reviewing the relevant sections of the law, you have further questions please contact the Department's Licensing Division for more information at 916-324-9046.

How long does it take to get licensed?

The timeframe can vary, however, it helps if the health care service plan is actively involved with the Department by scheduling pre-filing conferences, and submitting its required documents in a timely fashion.

What happens with the fines assessed against a health plan?

The fines assessed are deposited into the Managed Care Administrative Fines and Penalties Fund, which supports the Medically Underserved Account for Physicians in the Health Professions Education Fund (a loan repayment program for physicians who serve medically underserved populations) and the Major Risk Medical Insurance Program (a program that provides health care to individuals who would not normally qualify for private health coverage).

Does the enrollee get the money?

The DMHC does not represent the enrollee in enforcement actions against a health care service plan. Thus, the enrollee does not receive any portion of the fines. The investigation is not a substitute for civil litigation or any remedies an enrollee may seek against the plan.

As a health care service plan, am I required to file reports under SB 260?

Every health care service plan that contracts with a risk-bearing organization shall submit a quarterly survey listing all its contracting organizations, including their names, addresses, contact persons, telephone numbers, and number of enrollees assigned to the organization as of the last day of the quarter being reported and not more than forty five (45) days after the close of each subsequent calendar quarter.

Along with the quarterly report, every plan shall submit an annual survey report due by May 15 of each year, containing the specific information as required under California Code of Regulations, Title 28, §1300.75.4.3.

As a health care service plan, what are my reporting obligations under AB 1455?

Within 60 days of the close of each calendar quarter, the health care service plan shall disclose to the DMHC (A) any emerging patterns of claims payment deficiencies; (B) whether any of its claims processing organizations or capitated providers failed to timely and accurately reimburse 95% of its claims (including the payment of interest and penalties); and (C) the corrective action that has been undertaken over the preceding two quarters.

Within 15 days of the close of each calendar year, beginning with the 2004 calendar year, the plan shall submit to the Director, as part of the Annual Plan Claims Payment and Dispute Resolution Mechanism Report information disclosing the claims payment compliance status of the plan and each of its claims processing organizations and capitated providers. The Annual Plan Claims Payment and Dispute Resolution Mechanism Report for 2004 shall include claims payment and dispute resolution data received from October 1, 2003 through September 30, 2004. Each subsequent Annual Plan Claims Payment and Dispute Resolution Mechanism Report shall include claims payment and dispute resolution data received for the last calendar quarter of the year preceding the reporting year and the first three calendar quarters for the reporting year. 

Claim Payment Problems

What should I do if I have a problem getting paid by a payor?

The Knox-Keene Act and its implementing Regulations require each Health Care Service Plan to provide "a fast, fair and cost-effective dispute resolution mechanism under which providers may submit disputes to the plan". You should always first try to resolve your concern directly with the Health Care Service Plan, through its dispute resolution mechanism. If you disagree with the payor's dispute resolution response, you may submit a complaint through the Department's website.

What if I have a problem with a medical group?

You may report problems with a medical group using the methods described above, if the medical group is the payor. If you report a problem regarding a medical group, we will monitor the organization directly and through the health plans with which it contracts.

What is the department doing to resolve some of these problems with providers not getting paid?

The Department is monitoring carefully all complaints submitted by providers regarding problems with health plans and payors. We look for patterns or systemic problems and address them with individual health plans or payors through a number of oversight tools, including financial audits and medical surveys. Additionally, we can and will take enforcement action against health plans found to violate the law. To date the Provider Complaint unit has recovered more than $20,000,000 in reimbursements for providers.

What does the review process consist of?

An Initial Review will be performed on all electronically filed provider complaints. This review will be based on the information provided within each complaint form filed. Data provided in these forms will be rigorously analyzed to look for evidence of payor "unfair payment patterns." It will also be used to identify prevalent types of payment or contract issues. This data will provide the basis of targeted Departmental follow-up investigations, and follow-up actions to eliminate the root cause of these problems.

A Case Review of provider complaints will be more limited, based on staff resources available, consistent with the Department’s priorities. This process will require a verification of the facts presented in an electronically filed complaint by comparing it with backup documentation. When substantive review of a complaint has been initiated, the Department will open a case file and will request the provider to submit backup documentation relative to the case. Upon receipt of the documentation, the Department will determine whether there is non-compliance with the provisions of the Knox-Keene Act, and its Regulations. In many instances, during substantive review, the DMHC will make a determination of whether claims should have been paid, or whether interest is due. Trend analysis of the results of substantive review will also supplement the findings of the initial review process, to insure appropriate follow-up.

What do I need to do to file a complaint with the Department Of Managed Health Care?

Before you file a complaint with the Department of Managed Health Care, you should submit a request for dispute resolution through your payor's dispute resolution mechanism. Then, if you disagree with the response, complete and submit a Provider Complaint Form with the Department.

No. The Department of Managed Health Care's complaint process does not take the place of a civil action. We cannot give legal advice or act as your attorney. The complaint process should not be considered a way to gather facts in preparation for any potential legal action. You can take legal action at any time during the complaint process. In the event that the claims comprising your complaint are in litigation the Department may, in its discretion, suspend or delay its investigation until after the civil adjudication of those claims.

What qualifies as a "like" multiple complaint?

"Like" complaints are ones where the issues are the same or very similar. For "like" complaints, the Payor's actions giving rise to the complaints would be the same or very similar for each complaint. For Example:

  • Payor fails to correctly pay claims for the same or very similar CPT codes or health care services;
  • Payor fails to correctly pay interest on claims where interest is owed;
  • Payor requests unnecessary documentation prior to paying claims for the same or very similar CPT codes or health care services;
  • Payor violates the same provision of the applicable contract in regards to the payment of each claim;
  • Payor is otherwise engaged in any other unjust payment pattern, such as those set forth in Title 28, California Code of Regulations section 1300.71 (a)(8)(A)-(T).

What kinds of complaints does the Help Center handle?

  • You can’t get the medicine or treatment you need.
  • You have to wait too long for a referral, authorization, test, or appointment.
  • You are being sent home from the hospital too soon.
  • You have a problem with a bill, claim, or co-pay.
  • You received a bill for emergency or urgent care.
  • You cannot get services in your language.
  • Your doctor or hospital is no longer with your health plan.

Does the Help Center act as my attorney?

No. The Help Center does not give legal advice or act as your attorney. We will review your issue through our IMR or Consumer Complaint process and let you know if your health plan must provide the service or item you are requesting.

How will my complaint be decided?

The IMR will be decided by qualified, independent clinicians who are not employed by your health plan. Your complaint will be decided by experienced analysts, nurse consultants or lawyers. The Help Center will send you and your health plan a letter that explains our decision. If the complaint is decided in your favor, we will require your health plan to provide or pay for the service, or do whatever is needed to resolve the complaint. If the complaint is not decided in your favor, you cannot appeal the decision. However, you may still be able to take legal action and may want to speak with a private attorney.

Consumer Participation Program

The Consumer Participation Program is a program that awards reasonable advocacy and witness fees to any person or organization that represents the interests of consumers and has made a substantial contribution on behalf of consumers to the adoption of any regulation or to a Director's order or Director's decision, which affects a substantial number of consumers.

Which law made this program possible?

The Consumer Participation Program is made possible by section 1348.9 of the Knox-Keene Act. The statute is clarified at Title 28, Article 2, Section 1010 of the California Code of Regulations.

How many forms must I complete in order to receive an award of fees?

There are 3 forms. The first form, the Finding of Eligibility to Participate and Seek Compensation form, is to see if you substantially advocate on behalf of health care consumers. The second form, Petition to Participate in a Proceeding Form, approves you to participate in a specific proceeding and seek an award of fees. The third form, the Application for an Award of Advocacy and Witness Fees, is the actual request for fees.

What would make an applicant eligible to seek compensation?

  • The applicant represents consumers including a description of the applicant's experience in advocating on behalf of health care consumers in administrative or legislative proceedings.
  • The applicant is not employed by a health care service plan or specialized health care service plan.
  • The proceeding is not regarding resolution of individual grievances, complaints or, cases.

How long does the Department have to make a decision on if I may seek compensation?

The Department has 30 days, after the receipt of a completed application, to decide if you are eligible.

How long is an applicant eligible if they complete the Finding of Eligibility to Participate and Seek Compensation Form and are approved?

The finding of eligibility is valid for 2 years so long as the Applicant continues to represent the interests of consumers.

What is the Petition to Participate in a Proceeding Form?

Approval of this form identifies you as eligible for a specific proceeding. A person desiring to participate in a proceeding and seek an award of fees may submit a Petition to Participate in a Proceeding Form. Periodically, the Director may identify regulatory proceedings in which he or she believes consumer participation would be helpful and anticipates that fees may be awarded. This doesn't limit compensation only to those proceedings on the Director's list.

Is there a time limit on how long a Petition to Participate in a Proceeding Form may be submitted?

The Petition to Participate in a Proceeding Form will be submitted no later than the end of the public comment period or the date of the first of public hearing in the proceeding in which the proposed Applicant seeks to become involved, whichever is later. For orders or decisions, the request will be submitted within 10 working days after the order or decision becomes final.

How long does the Department have to approve or deny my Petition to Participate in a Proceeding Form?

The Department has 30 days, after the receipt of a completed application, to approve or deny the Petition to Participate in a Proceeding Form.

I have been approved for Petition to Participate in a Proceeding, what is my next step?

If you have made a substantial contribution to the proceeding, you must complete and submit the Application for an Award of Advocacy and WitnessFees within 60 days of the regulation, Director's order, or Director's decision.

How will I be notified if I am to receive an award of fees?

You will receive an approval letter via email.

What if I have participated in a proceeding and object to an application regarding the same proceeding?

Once an Application for an Award of Advocacy and Witness Fees has been received, it is posted on our website. You may use the "objection form" to object to that application. The Application for an Award of Advocacy and Witness Fees will be posted for 30 days. During that time, you may submit your objection form, objections will not be accepted after the 30th day.

What are the criteria to receive an award of compensation?

  • Applicant must have made a substantial contribution in representing consumers in an administrative proceeding, regulation, order, or decision. This must be supported by specific citations to the record, Applicant's testimony, cross-examination, arguments, briefs, letters, motions, discovery, or any other appropriate evidence.
  • Applicant must have completed the Finding of Eligibility to Participate and Seek Compensation Form and received approval or completed the Petition to Participate in a Proceeding Form and received approval.
  • A detailed, itemized description of the advocacy and witness services for which the Applicant seeks compensation.
  • Legible time and/or billing records created contemporaneously when the work was performed, which show the date and the exact amount of time spent on each specific task.

Will I receive the entire amount I applied for?

The hearing officer will determine the amount of compensation to be paid, which may be all or part of the amount claimed.

Can I appeal the hearing officer's decision?

Within 30 days of the hearing officer's decision, you may appeal to the Director for a review of the decision. The notice of appeal should state the relief that the Applicant is seeking and the reasons why the decision by the hearing officer should be modified or changed.

Can I appeal the Director's decision?

The Director's decision is final and there is no further administrative remedy.

Once I apply, is my information kept confidential?

All of the applications are subject to public disclosure under the California Public Records Act.

How much is the Department able to award during the year?

The Department may award up to a total of $350,000 for each fiscal year.