Skip Navigation LinksSite Map > Health Care Providers > Claim Issues > About The Provider Complaints Process


About the Provider Complaints Process

The Department of Managed Health Care recognizes that billing by providers and the handling of claims by health care service plans and their capitated providers are essential components of the health care delivery system. It has committed to make both more effective and efficient. This web page has been designed as part of a pilot project to accept and review provider complaints. The new electronic submission will allow the Department to look at complaint submissions to ensure that health plans and their capitated providers have implemented claims processing standards, contract disclosures and the dispute resolution mandates of the Knox Keene Health Care Service Plans Act (AB1455).

The Department's area of authority is limited to Health Maintenance Organizations (HMOs) and two PPO's - Blue Cross and Blue Shield of California. Before reporting a problem with a health plan, you should verify that the plan is regulated by the Department. To view a list of the plans regulated by the Department of Managed Health Care, go to HMO Reports.

Complaints within this area of jurisdiction will be closely reviewed in two steps:

  • Unfair Payment Pattern and Emerging Trend Analysis will be performed on ALL electronically filed provider complaints, including any which have not gone through the payor dispute resolution process. This review will be based on tracking and trending of the information provided within each complaint form filed. Data provided in these forms will be analyzed and reported to a Departmental Executive Review Committee, which will conduct monthly reviews to look for evidence of payor "unfair payment patterns." This group will be looking for prevalent types of payment, payor or contract issue problems. This analysis will help identify patterns of dissatisfaction with the existing Payor dispute resolution process. The data accumulated will provide the basis of targeted Departmental follow-up investigations, and follow-up actions to eliminate the root cause of these problems.


  • Case Review of provider complaints will be more limited based on staffing available to conduct these reviews. This process will require a verification of the facts presented in an electronically filed complaint by comparing it with relevant documentation. When a Case Review has been initiated, the Department will open a case file and will request the provider to submit relevant documentation. Upon receipt of the documentation, the Department will determine whether there is non-compliance with the provisions of the Knox-Keene Act, and its recent amendments in AB1455(2001). In many instances, a case review will make a determination of whether claims should have been paid, or whether interest is due. In-depth analysis of the results of case reviews will also supplement the findings of Emerging Trend Analysis, to insure appropriate follow-up.

The Department recognizes that it is important for hospitals, doctors and other providers to be paid promptly and accurately, and our Provider Complaint process is offered as a primary means of ensuring prompt payment.