Claims Payment Policies and Practices

Qualified Health Plan Issuers have provided information to help you understand what is needed for a claim to be paid, or why a claim was denied.

Click the links below to see the information the issuers have provided.

Anthem Blue Cross

A claim is a request to apply benefits for your health care coverage. Claims are submitted to Anthem Blue Cross for health care services, supplies, drugs, and/or equipment that are provided to you. In most cases, In Network Providers will send claims to Anthem Blue Cross for you. But if you received from an Out of Network Provider that does not send the claim to Anthem Blue Cross, it is your responsibility to do so. If you are sending a claim to Anthem Blue Cross, we must receive the Claim Form within fifteen (15) months from the date of service in order for Anthem Blue Cross to determine benefits. You can get a copy of the Claim Form at www.anthem.com/ca and selecting Customer Support – Forms Library or by contacting Anthem Blue Cross Customer Service at the number listed on your identification card. Anthem Blue Cross will determine if benefits are due in a timely manner. This is typically within thirty (30) days of receiving the claim.

In Network Providers have an agreement with Anthem Blue Cross. Out of Network Providers do not have an agreement with Anthem Blue Cross. Your personal financial costs when using Out of Network Providers may be considerably higher than when you use In Network Providers. When using Out of Network Providers for non-emergency services, in addition to any deductible, coinsurance, or copayment responsibility you may have, you will also be responsible for any balance of a Provider’s bill that is above the Maximum Allowed Amount determined by Anthem Blue Cross.

Anthem Blue Cross wants you to understand the benefits of your health care coverage so you can maximize your health care coverage with us. Anthem Blue Cross offers a variety of ways to assist and educate you. For detailed information regarding the benefits of your plan, please refer to your Combined Evidence of Coverage and Disclosure Form. You can access video tutorials, including the Claims process, by clicking here. When logged in to www.anthem.com/ca you can also send messages to us electronically. Anthem Blue Cross is also available to answer any questions you have by contacting our Customer Service number listed on your identification card.

Blue Shield of California

Member Claims

The Blue Shield health plan is designed for Members to obtain services from Participating Providers. However, members may choose to seek services from Non-participating Providers for most services. Covered services obtained from Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider. Detailed benefit information is available in the Evidence of Coverage and Health Service Agreement.

To determine whether a provider is a Participating Provider call the Customer Service number on your ID card or visit www.blueshieldca.com.

Participating Providers will submit claims for payment directly to Blue Shield, however, there may be times when Members and Non-Participating providers need to submit claims. Claims for payment must be submitted to Blue Shield within one year after the month services were provided.

To submit a claim for payment, the member can send a copy of the itemized bill, along with the completed Blue Shield Claim Form to:

Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540

A claim form is not a required document as long as the billing received contains enough information to identify the member’s account in addition to the itemized billing which includes:

  • Patient name
  • Date of service
  • Billed charge for each service
  • Procedure code for each service
  • Diagnosis code
  • Provider name, address and tax identification number

Blue Shield must have this information to process the claim, and the information must come from the doctor on their billing form. The following valuable information is available by visiting www.blueshieldca.com :

  • Claim form
  • Copy of ID cards
  • Benefit information
  • Deductible and copayment status

Blue Shield will notify the member of its determination within 30 days after receipt of a claim.

A claim would be denied for the following:

  • Incomplete Claim information
  • Lack of eligibility
  • Services are not a benefit of the plan
  • Not medically necessary, or experimental or investigational
  • Duplicate Claim (Claim billed more than once for specific visit and procedure)
  • Clinical code editing-doctor splitting up charges erroneously or fraudulently
  • Authorization requirements were not met

Provider Claims

Blue Shield allows providers to submit claims up to one year after the date of service occurs, however most Blue Shield hospital contracts require that claims are submitted no later than 180 days after date of service. On average providers submit claims within 30 to 40 days.

CCHP Health Plan

Chinese Community Health Plan is designed for Members to obtain services from a network of doctors. Members may choose to receive services from doctors outside this network. Covered services obtained from out of network providers may result in a higher share of cost for the Member. Certain medical services might need to be pre-authorization by CCHP before the plan will cover it. Some services are not covered unless given by a network provider. Please refer the plan Evidence of Coverage and Summary of Benefit for additional information.

Contracted providers have 90 days to bill claims to CCHP for services provided to Members. Out of network providers or non-contracted providers have six (6) months to bill CCHP for services provider to Members. CCHP process claims within 45 days from the date of receipt.

Members can submit a Reimbursement Request within 90 days from the date of service. This request form is available through our Member Services or CCHP website. Members need to submit the Reimbursement Form to CCHP and attach all necessary information including receipts and medical reports or records to support the request. Once the request is processed in the claims system and the reimbursement is approved, CCHP issues a check directly to the Member.

Health Net

Claims for Covered Services

Through Covered CaliforniaTM, Health Net of California, Inc. offers HMO and HSP plans. Health Net Life Insurance Company EPO plans are also available.

All three of these plans come with a specific doctor network. Members must use the network that comes with their plan for all covered services. There is no coverage for out-of-network services except for urgent or emergency care, or if pre-approved by Health Net.

When you use in-network services, your doctor (or other provider) sends the claim to Health Net. There’s no paperwork for you! Just remember to keep your Explanation of Benefits (EOB) for your records.

Explanation of Benefits (EOBs)

An EOB is not a bill. It is a brief description of the benefits that apply to the services you received. It also shows details about services you received; like the amount your provider billed Health Net, the amount Health Net paid and the portion of services that may be your responsibility.

  • The sample EOB below shows the most common sections. Depending on the services you receive and your plan type, your EOB may have data in the same or different areas. Explanation of Benefits Instructions (pdf)

Filing a claim

You may have to file a claim if you get urgent or emergency services, or for pre-approved services.

Medical claims

  1. Download and complete one claim form for each member submitting bills for reimbursement.
  2. Mail your claim to:

    Health Net of California, Inc. / Health Net Life Insurance Company
    Commercial Claims
    PO Box 14702
    Lexington, KY 40512-4702

Balance Billing

Balance billing happens when doctors bill you for the difference between the charges they billed and the amount covered by your health plan. Doctors who are part of Health Net’s Community Care HMO, PureCare HSP and PureCare One EPO networks do not balance bill our members.

If you get services outside the network that comes with your plan, the doctor may bill you. Health Net will not cover any part of the bill unless it was for urgent or emergency services, or if we pre-approved the out-of-network service. You will have to pay the full amount.

Coverage with more than one health plan

Health Net will manage benefits for members covered by two or more health plans to make sure payments are correct. This is called coordination of benefits (COB).

Paying premiums

Your premium payment, the amount you pay for your health plan, is due the first day of each month. A grace period is the time we add to allow you to make your premium payment after the due date. There is not a gap in coverage during the grace period. The length of the grace period depends on which plan you are enrolled in.

30-day grace period for all members

  • The 30-day grace period begins on the 2nd day of the month, with no gap in coverage.
  • Your coverage remains after the 30 days as long as all past due premium payments are paid. If not paid for, your health coverage will end at the end of the grace period.

90-day grace period for members who get premium tax credits

Enrolled members who receive premium payment tax credits have a three-month (90-day) grace period.

  • Month 1
    1. Health Net will continue coverage during your grace period.
    2. You still need to pay your premium payments. You also need to pay all copayments, coinsurance or deductible amounts required under the plan contract for this period.
  • Months 2 and 3
    1. Health Net will hold/pend your claims until you have paid all past due premium payments to us.
    2. You will keep getting monthly premium payment bills. This means your total amount due will go up each month that you don’t pay.
  • At the end of the grace period
    1. Your health plan will end due to nonpayment of premiums if Health Net does not receive all premium payment amounts due through the grace period. The total is due by the last day of the grace period. Any claims or authorizations that were held/pended will be denied.
    2. You will still owe the unpaid premium amount. You also have to pay for any health care services you received during months 2 and 3. This includes emergency care. If your health plan is ended for nonpayment of premiums, the end date of your health plan will be the last day of the first month of the three-month grace period.

Denied claims

Under certain conditions, we may deny a claim after you receive services. This is called a retroactive denial. Examples include, but may not be limited to:

  • You were not eligible at the time of service.
  • The service was not a covered plan benefit. Or, services were out-of-network.
  • An approval was needed and not received before the services were given.

You can help avoid retroactive denials by:

  • Paying your premium payments on time.
  • Knowing your plan benefits, knowing the approval needed before services are given and knowing your maximum benefit limits.

Prior authorization

  • Prior authorization is a review process. Health Net uses prior authorizations to approve a request to access a covered benefit before you receive the benefit.
  • The purpose of the review is to find out if your benefits apply, what is needed medically, and whether the treatment proposed is correct. Other conditions reviewed are level of care, length of stay or place of service.
  • Health Net maintains a list of drugs, devices, procedures, and other medical services that require prior authorization.

Medical necessity

Medical necessity is used to describe care that is reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care.

Prescription drugs

The list of drugs we cover is called the Health Net Essential Rx Drug List.

  • For medications not on the list:
    • You can ask your doctor to prescribe one that is on the list.
    • Or, your doctor can call us to ask approval for a drug not on the list and that is not excluded from coverage. These are called non-formulary drugs.
    • Health Net will determine coverage approval no later than 72 hours after getting the request.
  • If you have a condition that might threaten your life, health or ability to function normally if not treated right away (exigency), or if you are currently getting treatment using a drug that is not on the Essential Rx Drug list, and not continuing the drug would create an urgent (exigent) circumstance, then you, your designee or your doctor can ask for an expedited review.
    • Expedited requests for prior authorization will be processed within 24 hours after Health Net’s receipt of the request and any additional information requested.
  • To request a refund for prescription drugs:
    1. Download and complete one claim form for each member submitting bills for reimbursement.
    2. Mail your claim to:

      Health Net of California
      C/O Caremark
      PO Box 52136
      Phoenix, AZ 85072-2136

Customer Service

If you have questions about your Health Net plan call Customer Service:

Customer Service 1-888-926-4988
24-hour Automated Payment Line 1-800-539-4193
TTY (hearing and speech impaired) 1-888-926-5180

Kaiser Permanente

Kaiser is not a claims based model, therefore not applicable.

LA Care Health Plan

Claims and Payment

Filing Deadline
L.A. Care’s timeframe for receipt of an ‘initial claim’ submission is 90 days for contracted providers after the date of service for timely filing for a new claim except for when a contract allows for a different timeframe. The timeframe for receipt of an ‘initial claim’ submission is 180 days for non-contracted providers after the date of service for timely filing for a new claim.

Billing
All paper claims must be submitted on CMS 1500 form for professional services and UB-04 form for facility services. LA Care accepts EDI submissions partnering with Office Alley and Emdeon. Providers must use good faith effort to bill with the most current coding available.

The following information must be included on every claim:

Professional and Supplier Claims
Providers sending professional and supplier claims to L.A. Care Health Plan on paper must use Form CMS 1500 in a valid version. This form is maintained by the National Uniform Claim Committee (NUCC), an industry organization in which CMS participates.

Institutional Providers:
The completed UB 04 data set or its successor format adopted by the National Uniform Billing Committee (NUBC), submitted in the designated paper or electronic format as adopted by the NUBC. Entries stated as mandatory by NUBC and required by federal statue and regulations and any state designated data requirements included in statues or regulation.

If a claim is submitted with incomplete or invalid information, it may be returned to the submitter as unprocessable. Examples:

Unprocessable Claim - Any claim with incomplete or missing, required information, or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally.

Incomplete Information - Missing, required, or conditional information on a claim (e.g., no Unique Physician Identification Number (UPIN) / Provider Identification Number (PIN) or National Provider Identifier (NPI) when effective).

Invalid Information - Complete required or conditional information on a claim that is illogical, or incorrect (e.g., incorrect UPIN/PIN or NPI when effective), or no longer in effect (e.g., an expired number).

Claims Adjudication

For Covered California Members, LA Care Health Plan is allowed 45 working days from the day of receipt to finalize a claim. Interest is due on a late paid claim.

Each claim is subject to a comprehensive series of quality checks called “edits” and “audits.” Quality checks verify and validate all claim information to determine if the claim should be paid, denied or suspended for manual review. Edit and audit checks include but is not limited to verification of:

  • Data validity
  • Procedure and diagnosis compatibility
  • Provider eligibility on date of service
  • Recipient eligibility on date of service
  • Medicare or other insurance coverage
  • Claim duplication
  • Authorization requirements

Provider Portal Claims Verification

The L.A. Care Provider Portal is the preferred method for contracted providers to check claims status. Please see information on how to access the L.A. Care Provider Portal in the Provider Portal section of this handbook.

The secondary method to check claims status is by calling 1-866-LA-CARE6.

Balanced Billing

Balance billing L.A. Care members is prohibited by law. Contracted providers cannot collect reimbursement from an L.A. Care member or persons acting on behalf of a member for any services provided, except to collect any authorized share of cost.

Molina Healthcare

Your Molina health plan is designed for you to obtain covered services from participating (in-network) providers in order to provide you with the best value. Because in-network providers have an agreement with Molina, you should not expect to pay for extra charges outside your deductible, copayments or coinsurance. The contract between your provider and Molina places the responsibility for verifying eligibility and obtaining approval for those services that require prior authorization on your provider. Once you have obtained covered services from a participating provider, the provider is responsible for submission of claims to Molina for determination of payment under your plan. You are not responsible for submitting claims to Molina for payment of benefits under your plan. However, if a participating provider fails to submit a claim, you may wish to send receipts for covered services to Molina. With the exception of any required cost sharing amounts, if you have paid for a covered service or prescription that was approved or does not require approval, Molina will pay you back. Please refer to your evidence of coverage, policy, or certificate. For medical services, please also include medical records of the service received and a letter of explanation as to why you paid for the service. You will need to mail or fax Molina a copy of the bill from the doctor, hospital, or pharmacy and a copy of your receipt. If the bill is for a prescription, you will need to include a copy of the prescription label. Mail this information to the Molina Appeals and Grievance Department 200 Oceangate, Suite 100 Long Beach, Ca 90802 or fax it to (562) 499-0757.

For in-network services, your provider will submit a claim for services provided to you and you can expect that Molina will work with your provider to resolve that claim. The receipt of a clean, complete claim is acknowledged within two (2) working days of receipt if the claim was submitted electronically, or fifteen (15) working days if the claim was submitted by paper. Claims are processed for payment or denial within forty-five (45) working days from the date of receipt. Claims must be submitted by providers generally within ninety (90) calendar days from the date of service.

However, non-emergency services provided by non-participating (out-of-network) providers are not covered services, unless you work with your treating physician and with Molina to obtain authorization for those services prior to receiving them. Such authorized services must be billed to Molina within one hundred eighty (180) days of the service being provided. For unauthorized, out-of-network services, you will be 100% responsible for payment to non-participating providers and those payments will not apply to any applicable deductible or annual out-of-pocket maximum under your plan. Even when services are authorized, an out-of-network provider might bill you directly for the difference between what they charge and what Molina is able to pay as an allowed amount for their service. These balance-billed charges are your responsibility.

In general, staying in network, outside of emergency situations, is the best course for you to get the most out of your Molina health plan.

Oscar

A claim is incurred on the date the service is provided to You. You must be enrolled and eligible in an Oscar plan to receive benefits on the date the service is provided. We only provide benefits for Covered Services that are Medically Necessary, as outlined in Your Subscriber Agreement and Combined Evidence of Coverage and Disclosure. You must satisfy the In-Network medical Deductible before We will make payment for services You receive, except for certain services. These services, as well as Copayments and Coinsurance, are outlined in Your Summary of Benefits and Coverage.

You are responsible for confirming that the Provider You are seeing or have been referred to see is an In-Network Provider under Your Plan. With the exception of Authorized Referrals, Emergency and Urgent Care, any claims incurred with a Provider who is not a part of Your Plan’s In-Network Providers, will not be covered. Oscar can help You find an In-Network Provider specific to Your Plan by calling customer service at 1-855-Oscar-55 or visit Us at www.hioscar.com.

Oscar follows all Department of Managed Health Care regulations when it comes to the payment of claims. When using an In-Network Provider they will bill Oscar directly for services rendered to You. In order for the Provider to submit a claim on Your behalf, You must give the Provider information necessary for the claim to be filed, such as Your Oscar ID card.

Contracted providers must submit claims within one hundred eighty (180) calendar days following the dates of service, unless otherwise mandated by law or in the provider contract. A claim received after the timeframe may be subject to a denial.

For Out-of-Network Emergency or Urgent Care Covered Services, we must receive written notice of claims within one-hundred eighty (180) days, or as soon thereafter as reasonably possible.

Either the Subscriber or Provider of service must claim benefits by sending Us properly completed claim forms itemizing the services or supplies received and the charges.

When You receive Covered Services outside of the United States, You will need to submit an itemized bill (including charges) and medical records, translated into English, within one-hundred eighty (180) days.

Claim forms must be used and are available by accessing our web site at www.hioscar.com or by calling 1-855-Oscar-55. You should make copies of the documents for Your records, attach the original bills to the completed member claim form, and mail to Us as instructed.

Any benefits determined to be due under this Agreement shall be paid within thirty (30) working days after We receive a complete written proof of loss and determination that benefits are payable.

If You have a complaint or grievance concerning a claim, or any other matter, please call customer service at 1-855-Oscar-55. You may request a copy of the grievance form to complete and return to us. You may also ask the customer service representative to complete the form for You over the telephone. You may also submit a grievance form online in the “Members” section at www.hioscar.com. You must submit Your grievance to Us no later than one-hundred eighty (180) days following the date You receive a denial notice or any other incident or action with which You are dissatisfied. You must include all pertinent information from Your identification card and the details and circumstances of Your concern or problem. Upon receipt of Your grievance, Your issue will become part of our formal grievance process and will be resolved accordingly.

Sharp Health Plan

Sharp Health Plan is a San Diego-based health care service plan licensed by the State of California. Sharp Health Plan is a managed care system that combines comprehensive medical and preventive care in one plan. You receive preventive care and health care services from a network of providers who are focused on keeping you healthy. You have the added convenience of not submitting paperwork or bills for reimbursement. Providers send their claims for covered benefits you receive directly to Sharp Health Plan or the applicable medical group. If you receive a bill from a provider for covered benefits you received, please contact Customer Care at 1-800-359-2002 or customer.service@sharp.com. Sharp Health Plan will contact the provider and give him/her the information needed to send their claim to Sharp Health Plan.

Some non-contracted providers may require that you pay for emergency or urgent care services and seek reimbursement from Sharp Health Plan. On these occasions, request an itemized bill of all services received and a copy of the medical report. To request reimbursement, go to sharphealthplan.com or call Customer Care to request a member reimbursement form. Send the completed member reimbursement form, itemized bill, and medical records to Sharp Health Plan at the address listed on the form.

You must send your request for reimbursement to Sharp Health Plan within 180 calendar days of the date you received care. If you are unable to submit your request within 180 calendar days of the date you received care, please provide documentation showing why it was not reasonably possible to submit the information within 180 days. Sharp Health Plan will make a decision about your request for reimbursement and, as applicable, send you a reimbursement check within 30 calendar days of receiving your complete information. If any portion of the reimbursement request is not covered by Sharp Health Plan, we will send you a letter explaining the reason for the denial and outlining your appeal rights.

Valley Health Plan

Member Claims

The VHP website has complete directions on how to submit a claim for services members might incur out of plan. Members would only be submitting claims for services that were provided for out of area Emergency or Urgent Care services at a non-contracted provider, from a pre-approved referral to a non-contracted provider, or for a prescription when local network pharmacies are closed.

For care that is provided at an in-network contracted provider, there should be no need for the member to submit their own claim.

The link for members that provides directions on how to submit a claim is: www.valleyhealthplan.org/sites/ccp/mm/FormsResources/Pages/MedicalClaimReimbursementForm.aspx

This link provides members − in English, Spanish and Vietnamese − the forms and instructions on how to submit a claim form and the time frames associated with reimbursement back to the member.

Provider Claims

Providers that have a contract with VHP must submit their claims within 90 days. Non-contracted providers have up to 180 days to submit a claim to VHP.

VHP has 45 business days to process a clean claim form the time of receipt.

Western Health Advantage

Both Provider and Consumer claims are processed within 45 working days from the received date of the claim. Under most circumstance, claims should be submitted within 90 days from the date-of-service for provider, 180 days for Consumers. Prior to obtaining services, Providers and Consumers should ensure, if applicable, the services were authorized. If there are questions about a service or authorizations, please contact your PCP, the PCP’s assigned medical group or IPA, or the service provider. If any additional assistance is needed, please contact WHA Member Services.

How and when a Consumer can file a claim

It is important that you present your member ID card at the time of service. The provider will need the information found on your member ID card to bill WHA for the Covered Service(s).

In the unlikely event that you pay for a Covered Service out-of-pocket, you will need to mail or fax the following information to WHA for reimbursement. The Reimbursement Request form can be accessed by logging into your MyWHA account.

  1. A signed and dated summary/explanation detailing the service you received
  2. Any supporting documentation from the provider who performed this service
  3. Proof of payment
  4. Your contact information, including:
    • Full name
    • Phone number
    • Mailing address
    • Email address
    • WHA member ID

Once WHA receives the above information, you will be notified within 45 business days regarding the outcome of your claim.

Please note: Only services covered under your plan are eligible for reimbursement. Your plan's applicable copayment/coinsurance and/or deductible will determine the total amount you are reimbursed.

For a prescription-only reimbursement contact Express Scripts, WHA’s pharmacy benefit manager, online at express-scripts.com or by calling 800.9038664.

For more information, contact:

Claim Services
916.563.2250 or 888.563.2250 toll-free
Monday through Friday (excluding holidays) 8 a.m. to 6 p.m.
For TDD/TYY: 888.877.5378
Email: memberservices@westernhealth.com or use the Secure Message Center
Fax: 916.568.0126 

If you haven’t done so all ready, be sure to visit mywha.org, click “Sign Up for MyWHA Tools” and follow the prompts. Once you are registered, you can download a copy of the Reimbursement Request form, see your personal benefit information, including copayment summaries and Combined Evidence of Coverage and Disclosure Form (EOC/DF).

Some common reasons a claim may be denied

  1. Lack of eligibility
  2. Non emergent care, no authorization
  3. Non-participating provider, no authorization
  4. Not a covered services/benefit per EOC or copayment summary

Right to an Appeal

An appeal is a verbal or written formal request to re-review or reconsider a decision that has been made. The appeal can be related to a payment issue, an administrative action, quality of care or service issue or utilization recommendation. Your appeal will be reviewed by a doctor who was not involved in the initial review of the issue. This doctor will make an independent second decision after reviewing all available information. The second decision may agree or disagree with the first decision.

Standard or routine appeals are completed within 30 calendar days. A delay in a final decision may occur if additional information is needed for the reviewer to make an informed decision.

Expedited or “fast track” appeals are completed within 72 hours upon request if delaying the appeal decision risks jeopardizing your health. You have the right to request a “fast track” or expedited appeal if your doctor agrees there are health risks in delaying the decision. WHA’s Medical Director or appropriately licensed designee will make the decision if the appeal will be handled as an expedited or standard appeal.

What is WHA's Grievance and Appeal Procedure?

If you have a complaint with regard to WHA’s failure to authorize, provide or pay for a service that you believe is covered, a cancellation, termination, non-renewal or rescission of your membership or any other complaint, please call Member Services for assistance. If your complaint is not resolved to your satisfaction after working with a Member Services representative, a verbal or written grievance or appeal may be submitted to:

Mail:Western Health Advantage
Attn: Grievance and Appeals
2349 Gateway Oaks Drive, Suite 100
Sacramento, CA 95833
Secure Fax:916.563.2207
Call:WHA Member Services
916.563.2250 or 888.563.2250
Secure Email:mywha.org/securemessage

You may also start the grievance process by completing WHA's online grievance form.

Please include a complete discussion of your questions or situation and your reasons for dissatisfaction and submit the grievance and appeal to WHA Member Services, Grievance and Appeals Department within one hundred eighty (180) days of the incident or action that caused your dissatisfaction. If you are unable to meet this period, please contact Member Services on how to proceed.

If you are appealing a denial of services included within an already-approved ongoing course of treatment, coverage for the approved services will be continued while the appeal is being decided.

If you believe that your membership has been or will be improperly canceled, rescinded or not renewed, you may request a review by the Department of Managed Health Care after participating in WHA’s grievance process for thirty (30) days. If your coverage is still in effect when you submit your grievance to WHA, your coverage will be continued while your grievance is being decided, including during the time it is being reviewed by the Department of Managed Health Care. All premiums must continue to be paid timely for coverage to continue. At the conclusion of the grievance, including any appeal to the Department of Managed Health Care, if the issue is decided in your favor, coverage will continue or you will be reinstated retroactively to the date your coverage was initially terminated. All premiums must be up to date and paid timely.

WHA sends an acknowledgment letter to the Member within five (5) calendar days of receipt of the Grievance or Appeal. A determination is rendered within thirty (30) calendar days of receipt of the Member’s Grievance or Appeal. WHA will notify the Member of the determination, in writing, within three (3) working days of the decision being rendered.

A grievance form and a description of the grievance procedures are available at every Medical Group and Plan facility. In addition, a grievance form will be promptly sent to you if you request one by calling Member Services. If you would like assistance in filing a grievance or an appeal, please call Member Services and a representative will assist you in completing the form or explain how to write your letter. We will also be happy to take the information over the phone verbally or through a secure message.

It is the policy of WHA to resolve all grievances and appeals within thirty (30) days of receipt. For appeals of denials of coverage or benefits, you will be given the opportunity to review the contents of the file and to submit testimony to be considered. Written notification of the disposition of the grievance or appeal will be sent to the Member and will include an explanation of the contractual or clinical rationale for the decision. Contact Member Services for more detailed information about the grievance and appeal procedure.

If you have a complaint about your dental, vision, chiropractic/acupuncture, or mental health services, contact our Plan partners for information regarding how to lodge a grievance or appeal.

Department of Managed Health Care Information

The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a Grievance against your health plan, you should first telephone your health plan at one of the numbers listed below 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 thirty (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 an 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 department also has a toll-free telephone number, 888.HMO.2219 (888.466.2219), and a TDD line, 877.688.9891, for the hearing and speech impaired. The department's Internet Web site, www.hmohelp.ca.gov, has Complaint forms, IMR application forms and instructions online. The Plan's Grievance process and the Department's Complaint review processes are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.

Non-Participating/Out-of-network Providers

Any coverage for services provided by a Physician or other health care provider who is not a Participating Provider requires written Prior Authorization before the service is obtained, except in Medically Necessary Emergency Care situations and Medically Necessary Urgent Care situations that arise outside WHA’s Service Area. If you receive services from a non-Participating Provider without first obtaining Prior Authorization from WHA or your Medical Group, you will be liable to pay the non-Participating Provider for the services you receive.

Balance billing

Non-participating hospitals and Physicians are prohibited under state law from billing you more than your applicable copayment and/or deductible for emergency services. When you receive emergency services from a non-participating hospital or Physician, WHA will receive a bill and will pay the reasonable and customary value for the services, as required by law. Regardless of the amount of the total billed charges, you are never responsible for more than your applicable copayment and/or deductible for emergency services. If you were billed more than your applicable copayment and/or deductible for emergency services provided by a nonparticipating hospital or Physician, you may report the provider to the California Department of Managed Health Care by calling 888.466.2219. You may also contact Member Services at one of the numbers listed below for assistance.