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Health Plan Compliance/Medical Survey

California Managed Care law requires the DMHC to conduct a routine medical survey of each licensed full service and specialty health plan at least once every three years. The medical survey is a comprehensive evaluation of the plan's compliance with the law in the following health plan program areas:

  • Quality Management
  • Grievances and Appeals (member complaints)
  • Access and Availability
  • Utilization Management (referrals and authorizations)
  • Overall plan performance in meeting enrollees' health care needs
When the survey is complete, the Department issues a final report that is available to the public. The DMHC will perform a follow-up survey within 18 months of the final report if any deficiencies remain uncorrected.

The Department's Division of Plan Surveys may also perform an investigative medical survey as often as deemed necessary by the DMHC's Director. This is to protect the interests of managed care members.

The schedule of upcoming routine health plan surveys is posted for the public.

Medical Technical Assistance Guides

The Department utilizes detailed audit tools when conducting medical surveys of both licensed full service and specialty plans in order to ensure compliance with the Knox-Keene Act (Act), Title 28 of the California Code of Regulations and other applicable laws and regulations. This generic protocol document, called a Technical Assistance Guide (TAG), is used by the surveyors to measure a plan's performance and determine compliance with relevant legal requirements. The standard TAG tools are updated as necessary based on legislative changes to the Act, as well as updated regulations.

The Department also develops audit tools based on statutes and regulations of the Act to conduct investigative or non-routine surveys that typically have a specific and limited scope. The Department TAGs are listed below and may be accessed through this page.

Full Service Technical Assistance Guides


Behavioral Health Technical Assistance Guides


Language Assistance Technical Assistance Guides


Dental Technical Assistance Guides


Vision Technical Assistance Guides


Chiropractic Technical Assistance Guides


1115 Waiver Guides

 

Cal MediConnect Technical Assistance Guides

 

Medi-Cal Dental Managed Care Technical Assistant Guides