An “unreasonable” request, according to the Department of Managed Health Care (DMHC), is one that exceeds the minimum level of information required for a competent claims adjudicator to determine the plan’s payment responsibility. California’s new unfair payment practices regulations authorize DMHC to penalize plans (and their contracting medical groups/IPAs) that make such unreasonable demands for documentation.

Physicians should consider keeping a log to record all health plan requests for medical records. (A sample log is available on CMA’s unfair payment practices CD-ROM, “Payor Abuse Matters: React Now.”)

It is important for physicians to report unfair health plan payment practices to the Department of Managed Health Care (DMHC), so the department can take action against plans (and their contracting medical groups/IPAs) that fail to comply with the new regulations. Provider complaint forms are available in the Unfair Payment Practices Resource Center.

Please contact CMA’s Center for Economic Services at 888/401-5911 prior to submitting a complaint to get help with filing the appropriate forms and supporting documentation to substantiate the complaint.

Please also fax a copy of your complaint to CMA’s Center for Economic Services at 916/551-2027. This will allow CMA reimbursement specialists to monitor DMHC enforcement.