The DMHC regulates health care service plans that deliver health, dental, vision and behavioral 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 Unit 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 payers under the DMHC’s jurisdiction. Also included are useful terms and information on DMHC licensed plans.
Prescription Drug Prior Authorization or Step Therapy Exception Request Form (61-211)
Pursuant to Senate Bill 282 and Assembly Bill 374, the Department of Managed Health Care 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.
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 non-contracting 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 as needed, but, at a minimum, on an annual basis. Health plans that require prior authorization for post-stabilization care are also required to provide non-contracting hospitals with this specific contact information.
Plan Post-stabilization Authorization Contact Information
Below is a link for health plans that demonstrates how to submit or update plan-specific contact information.
Patient Notices (California Health and Safety Code section 1262.8)
Non-contracting 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 non-contracting 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.
Printable Help Center "Get Help Now" Waiting Room Notices
Occasionally providers recommend services or treatments for their patients that are denied by the health plan. In such instances, the DMHC may be able to offer assistance.
As a service to California providers, the DMHC offers "Get Help Now" Notices in English and 15 other languages. Health care providers are not required to post these notices. However, all providers may do so voluntarily as a service to their patients.
English and 15 other languages of the "Get Help Now" Waiting Room Notices.
To obtain downloadable copies of the notices you would like to display: