How to File a Grievance Against a California HMO
- 1). Document your dispute. If you are disputing a decision not to cover a medical claim decision, get a letter of medical necessity from a doctor and collect all attending physicians' statements.
- 2). Exhaust your appeal options within the HMO itself using the procedures set forth in the plan description or policy documents you received when they issued your policy. Even if you don't get satisfaction from the company, your complaint may receive more weight at the state level if you have gone through this process.
- 3). Contact the office of the California Commissioner of Insurance. You can do so using the link to the health insurance complaint page listed in the Resources section. However, if you are disputing a workers' compensation claim, you must visit the Division of Workers Compensation website to file your complaint, and if you have a complaint regarding Medi-Cal, you must go through the Medi-Cal website.
- 4). Fill out a Health Care Provider Request for Assistance (HPRFA) form, which you can download from the Resources section. Return the form to Claims Services Bureau, 300 South Spring Street, South Tower, Los Angeles, CA 90013. Include any supporting documents, including claim forms submitted to the insurance company and a copy of the patient's insurance identification card.
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