What options do I have if I disagree with the insurance plan's payment decision ?

Any time a health care provider disagrees with a health plan’s payment decision, a payment dispute exists, which the health care provider can appeal through the plan’s provider dispute resolution process.

Legislation passed in 2000 requires managed care health plan processes for provider dispute resolution to be “fair, fast and cost effective.” A dispute resolution process that is not fair, fast and cost effective is essentially in violation of state law and the process itself can be challenged. The regulations also require plans to inform providers that they have the right to challenge a claim payment and to explain how providers can initiate a challenge. Again, if a dental plan’s reimbursement is different from the submitted claim, it constitutes a payment dispute and a plan that fails to provide notice that the payment decision can be challenged violates state regulations.

The DMHC regulations that require plans to have a process of provider dispute resolution do not address the nature or format of these appeals. They mainly mandate that each plan establish a process and a time frame within which to consider and decide on payment dispute challenges. Subsequent to the DMHC regulations, a similar provider dispute resolution requirement was placed in the Insurance Code, applying to preferred provider organizations regulated by the Department of Insurance.

However, if a plan decides to uphold its original payment decision, rejecting a challenge you have submitted, you have a right to a second level of appeal. That occurs through the Department of Managed Health Care itself, which has made such filings easy and continues to refine the process. The department has also recently increased its ability to review provider disputes. If you believe a payment was unjustly denied, you must first go through the plan’s provider dispute resolution process, and if the plan dismisses your challenge, file the dispute with the Department of Managed Health Care.