Health Care Providers Guide

5 Filing a complaint with the California Department of Insurance (CDI) Once you have determined that the plan is regulated by the CDI you should submit a dispute to the insurer for review under the Dispute Resolution Mechanism process. If you disagree with the decision or would like the California Department of Insurance to review an issue, you can submit a complaint by completing a Health Care Provider Request for Assistance (HPRFA). . .......... To ensure proper review of the case, the following documents should be sent to the Department: • A copy of the completed Health Care Provider Request for Assistance  form • Copy of the patient’s Assignment of Benefits documentation. • Copy of claim forms submitted to the insurance company • Copies of all correspondence between the provider and the insurancecompany, includingall related Explanationof Benefits (EOB) • Copy of the Dispute Resolution Mechanism process determination letter • Copy of the patient’s insurance identification card • Copy of the provider’s contract with the insurance company, if any Examples of the types of problems that you can submit to the CDI • Improper denial or delay in payment of a claim • Other claims handling issues • Dispute Resolution Mechanism difficulties • Misconduct of the health insurer