Claims
When a Claim Must be Filed
If you are a member of an HMO you must submit a request for payment of benefits for all services you receive from a non-HMO provider. Typically, HMOs only cover services provided by HMO providers. You will need to file a claim for any services, such as services provided during a medical emergency, provided by a non-HMO provider.
You should refer to your Evidence of Coverage or contact your HMO for specific instructions about what information you must supply and when it must be supplied. The time requirements for submitting a request vary by HMO. If you do not provide the information within the required time period, benefits for that health service may be denied or reduced, at the HMO's discretion.
Time Frames for Responding to Claims
Each HMO has specific procedures for addressing claims and appeals. The HMO may also require you to respond within specific time frames. The time frames for responding to claims depends on whether the claim is urgent (requiring approval prior to receiving medical care where a delay of treatment could seriously jeopardize life or health) or when the claim is — post service (after the service has been provided), pre-service (before service has been provided) or concurrent care (for extending ongoing treatment previously approved for a specific time period or number of treatments).
Appeals
If you have been denied a claim or believe you have been denied a benefit to which you may be entitled under an HMO's plan, you must go through the appeals steps provided by your HMO. You should refer to your EOC or call your HMO at the phone number listed on your ID card or the phone number listed in the summary of benefits chart for specific instructions on how and where to file an appeal. Be sure to follow these procedures carefully.
After you have initiated an appeal, in accordance with the steps outlined in your HMO's Evidence of Coverage (EOC), the HMO must respond to you within the prescribed time frames. The response you receive from your HMO will outline further steps available to you should your appeal be denied.
Because HMOs are not self-insured by the Company, HMO members do not have legal recourse to formally appeal to the Company after they have gone through all the appeals steps provided by the HMO. Although you should always feel free to bring issues relating to an HMO's service or quality of care to the Company's attention, the Company does not review formal appeals for benefits provided by HMOs.
For issues relating to eligibility or participation in an HMO, please refer to the Health Care Participation section.
Complaints
If you have any complaints or issues with your HMO, please call the California Department of Managed Health Care's (DMHC) HMO Help Center at:
888-HMO-2219
TDD: 877-688-9891
or visit the DMCH website at www.dmhc.ca.gov
If your health problem is urgent, or if you already filed a complaint and are not satisfied with your health plan's decision, contact the HMO Help Center at the Department of Managed Health Care (DMHC). An urgent problem is a serious threat to your health. You can also file a complaint with the HMO Help Center if your HMO does not make a decision within 30 days.
The HMO Help Center will assist you with your complaint. They will also provide you with an Independent Medical Review (IMR), if you qualify.
Filing a Complaint
You may file a complaint with the DMCH HMO Help Center if:
  • Your problem is urgent and waiting to finish your health plan's complaint (grievance) process will be a serious risk to your health.
  • You have not received a decision from your health plan within 30 days, or within 3 days if your problem is urgent.
  • You are not satisfied with your health plan's decision.
How to File a Complaint
To file an urgent complaint, call the HMO Help Center.
To file a complaint that is not urgent, visit the DHMC website and fill out and mail a Complaint Form.
There is no charge for your call. The HMO Help Center is open 24 hours a day, 7 days a week and can provide help in many languages. You may also email your complaint/problem by using the special contact form on the CMHC website.