DMHC-Required Statement on Written Correspondence
- Participating Physician Groups (PPG)
(does not apply to HSP)
- Los Angeles
- San Bernardino
- San Diego
- San Joaquin
The Department of Managed Health Care (DMHC) maintains a program to assist consumers with resolution of complaints involving HMOs. The DMHC requires that all written correspondence that could result in a member appeal or grievance, including claim denial letters, contain the following statement with the department's telephone numbers, the department's TDD line, the department's Internet address, and the plan's telephone number in 12-point boldface type in the following regular type statement:
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The DMHC also has a toll-free telephone number and a TDD line for the hearing and speech impaired. The DMHC website at www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.
The applicable Member Services Department telephone number for each line of business should also be included.