Payer Complaints
Filing a Complaint with the Monitor
Payers with a complaint regarding an alleged violation of the Competitive Impact Conditions, may request the Monitor to investigate their complaint. Payers may file their complaint with the Monitor or with the California Attorney General. Please note, all complaints filed, regardless of being filed with the Monitor or the California Attorney General, will be investigated, and a report and recommendation issued, by the Independent Monitor.
Definition of Payers
Pursuant to the definition of “Payer” in the Competitive Impact Conditions, the following parties meet the definition of Payer and can file a complaint with the Monitor or the California Attorney General regarding alleged competitive impact condition violations:
- An organization that sells licensed commercial or Medicare Advantage products, or administers MediCal benefits as a managed MediCal HMO.
- An organization licensed by the California Department of Insurance.
- An organization licensed by the California Department of Managed Health Care with a full or limited/restricted Knox Keene license, including independent physician organizations that hold a restricted/limited license and accept financial risk from full Knox Keene licensed health plans, Medicare Advantage health plans, or MediCal managed care health plans.
- Self-Funded Employers that have direct contracts with hospitals.
- An organization that is a licensed third-party administrator that makes networks available to self-funded employers, union trusts, and/or state and local government entities.
Organizations that do not meet the definition of “Payer” include:
- Kaiser entities;
- Commercial health plans or networks co-branded with any health care provider other than Huntington Hospital;
- Autopay – automobile insurance; and
- Leased Networks that do not provide third party administration services.
If you believe your organization meets the definition of “Payer” as defined above, please click here to file a complaint with the Monitor.