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• Dispute Resolution Process

Dispute Resolution Process

Payment Dispute Resolution Process for
Dentist Members of Dental Plan Networks

Both the California Health and Safety Code (Sec. 1371.1) affecting all Knox-Keene plans, and the Insurance Code (Sec. 10123.145) require payers to have in place a process for resolving provider payment disputes with payers. These statutes and rules enable providers to contest reimbursement decisions within 30 working days of a payer’s decision.

According to regulations adopted by the Department of Managed Health Care, which went into effect on Jan. 1, 2004:

• All health plans, including specialty plans, are required to have in place a provider dispute resolution mechanism which is “fast, fair, and cost-effective.”
• Plans were required to notify providers of their dispute resolution processes by Jan. 1, 2004.
• A provider dispute means a written notice to the plan “challenging, appealing, or asking reconsideration” of a claim that has been denied, adjusted or contested, or disputing a request from the plan for reimbursement of a reputed overpayment.
• Whenever a plan contests, adjusts, or denies a claim, it shall inform the provider of the availability of the provider dispute resolution mechanism and the procedures for obtaining forms and instructions for filing a challenge.
• Providers may submit a challenge to a plan’s payment decision within 365 days of the decision or action.
• Plans must acknowledge receipt of a provider’s dispute within two working days of receiving a challenge that is submitted electronically, and within 15 working days if submitted by mail.
• Determinations of a provider’s dispute must be made within 45 working days after receipt of the provider dispute.
• Plans must designate a principal officer who will be responsible for maintaining its dispute resolution mechanism.
• The provider dispute shall be handled and resolved by the plan without charge to the provider (any legal counsel retained by the provider is excluded from this requirement).
• Plans can determine the form of the dispute resolution mechanism they adopt, but arbitration shall not be that mechanism. The regulations require a mechanism that is a lower or intermediate process; arbitration may be an option that a provider chooses to use to resolve a payment dispute, but it cannot be the primary or exclusive mechanism the plan uses for resolving disputes with providers.

Plan dispute resolution mechanisms which are not “fast, fair, and cost-effective,” or which in any way violate the required notice to providers of the option to file a challenge, or which violate the timeframes within which a challenge must be responded to, may be reported to the California Department of Managed Health Care as a potential violation of the regulations. A plan’s “unjust” or “unfair payment pattern” should also be communicated to the Department of Managed Health Care for possible investigation and enforcement action.

The California Department of Insurance also requires insurers and health plans licensed under the State Insurance Code to provide internal dispute resolution mechanisms for health care providers to challenge adverse payment decisions. Upon completion of the internal review, if the care provider still disputes the insurance company’s payment decision, the dispute can be filed with the Consumer Services Division of the Department of Insurance. The department provides a form that dentists may file with the department. It’s also important to remember that patients may also file a complaint with the Department of Insurance over a payment dispute with their insurance company. Because of the department exists mainly to protect consumers, dentists should be encouraged to share pertinent information with their patients when a payment dispute arises with a patient’s insurance company.

Complaints or disputes over plans’ payment decisions should also be communicated to the California Dental Association at 800.232.7645. A pattern of possible unfair payment or business practices identified by CDA from member complaints may be taken up with the CDA’s Council on Policy Development for review and consideration of appropriate action. If a member wishes to contact the CDA about a payment dispute with a dental plan, please be prepared to share supporting documentation (e.g., copies of claims, remittances, correspondence with the plan, responses from the plan, and the like) regarding the payment dispute. Such documentation is necessary for staff to thoroughly bring issues before the Council on Policy Development.