Providers have two levels for appealing payment disputes with health plans. The first level is with the plan itself. Then, if a dispute is not resolved with the plan, the provider may appeal with the appropriate regulatory agency.
Both the California Health and Safety Code (Sec. 1371.38) affecting all Knox-Keene plans and the Insurance Code (Sec. 10123.137) affecting PPOs and indemnity insurance require payers to have in place a process for resolving provider payment disputes with payers. These statutes and rules enable providers to contest disputes about reimbursement decisions.
According to regulations adopted by the Department of Managed Health Care, all health plans, including specialty plans, are required to have in place a provider dispute resolution mechanism that is “fast, fair and cost-effective.”
The dispute process should include the following elements:
While dental plans must have an internal dispute resolution process in place for compliance with California law, self-funded dental plans are not under this obligation, as they are regulated by the federal Employees Retirement Income Security Act of 1974 (ERISA) rather than the laws of California. ERISA plans also include benefit plans offered by labor unions, multistate employers, divisions of government such as cities and counties, school districts, the state of California, the University of California and the California State University system. However, most self-funded ERISA-regulated health plans are administered by major insurers.
Consequently, the first step in appealing a payment dispute with a self-funded dental benefit plan is to file the dispute with the administrator under that company’s dispute resolution process.
Some plans do not provide specific forms, but many provide their process of appeal. (See plan links below.) If the plan does not have a specific form, you may choose to use the sample dispute form at the end of this resource.
If the plan’s resolution is not in your favor and you wish to continue the dispute resolution process, your next option is filing with the regulating agency of the plan.
Plan dispute resolution mechanisms that are not “fast, fair and cost-effective,” or that in any way violate the required notice to providers of the option to file a challenge or that violate the time frames within which a challenge must be responded to, may be reported to the 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. You can file a complaint online at Department of Managed Health Care.
ERISA plans – A subsequent avenue to resolve payment disputes with self-funded plans is to discuss the dispute with the patient, the patient’s employer or group and the Office of Participant Assistance with the U.S. Department of Labor’s Employee Benefits Security Administration.
Complaints or disputes over plans’ payment decisions may be communicated to the California Dental Association Practice Support team. A plan’s pattern of possible unfair payment or business practices is a concern for CDA and commonly identified from member complaints. Depending on the complaint or dispute, CDA may follow up with the appropriate state regulatory agency. Members who wish to contact CDA about a payment dispute with a dental plan should 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 Practice Support staff to thoroughly address members’ issues or, when necessary, to bring these cases to either the State Department of Managed Health Care or Department of Insurance.