Health Care Providers Guide

2 Who Regulates What Type of Plan? The majority of California’s health plans are regulated by either the California Department of Insurance (CDI) or the California Department of Managed Health Care (DMHC). The CDI regulates point-of-service health plans and certain Preferred Provider Organization (PPO) health plans underwritten by health insurance companies licensed by the CDI..... ........................................................ The CDI does not regulate Health Maintenance Organizations (HMOs)orcertainPPOs,whichfallundertheKnox-KeeneAct(i.e. BlueCross of California or Blue Shieldof California). Complaints against these types of health plans should be submitted to: Department of Managed Health Care (DMHC) 980 Ninth Street #500 Sacramento, CA 95814-2725 Web site: www.dmhc.ca.gov Provider Complaints: 1-877-525-1295 Introduction Existing law provides for the Insurance Commissioner to establish a program to investigate and respond to complaints concerning health insurers. Under existing law, a health insurer is required to reimburse a provider’s claim within a specified time frame or to provide a notice to the provider explaining its reasons for denying or contesting the claim. This guide was created to inform health care providers of their right to file a complaint with the California Department of Insurance (CDI) regarding the handling of a claim or other obligation under a health insurance policy by a health insurer or agent, or regarding the alleged misconduct by a health insurer or agent.