HMO Help

Help For Unpaid Claims:

Please note that all claims from LPG are sent certified signed receipt mail and double checked by two employee's. If you are being told that there is "no claim on file", please contact our staff for the certified receipt tracking number.

• 1. Don't be fooled or diverted by attempts to make you angry at the party that has not been paid for the services they provided to you. Ask questions, and control your temper -- the person on the phone is not the problem, but may possibly be your avenue to a solution. Some delays really are administrative errors that can be easily corrected.
• 2. Document who you are speaking to (title), when (date and time), where (location), and what department. Don't forget to get the phone number and extension of the person you are speaking to, and tell them you will call back to follow up in one week.
• 3. If your claim is not resolved in one week then move up the chain: ask to speak to the supervisor, the Benefits Supervisor, etc. Keep a record of every person you speak to (first and last name -- "Suzie" is not sufficient), and what you were told.
• 4. Follow up by sending a letter and then a formal written complaint to the Company's Claim Department, Complaint Department, and CEO. They have thirty days to resolve your dispute. If it is not resolved with in thirty days you may file a complaint with the Department of Managed Health Care (see link below).
• 5. Copy our free form letters to send on the HMOhelp letters page.
• 6. If you are having difficulty, ask the claims representative to do a three way call with your doctors office for assistance. This is also helpful when the insurance representative is telling you something different than what has been told to the doctors office.

Your Health Care Rights:

California Regulators Adopt Rules On Timely Access to Non-Emergency Care

SACRAMENTO, Calif.—Seven years after the enactment of legislation (A.B. 2179) directing it to do so, the California Department of Managed Health Care (DMHC) announced Jan. 20 it adopted regulations aimed at ensuring plan enrollees have timely access to health care services.

According to DMHC Director Cindy Ehnes, the new rules make California the first state to shorten the time a patient has to wait to see a doctor by requiring that managed care plans ensure member appointments with medical providers be scheduled within certain time frames. “California patients are literally sick of having to wait weeks to see a doctor,” Ehnes said in a Jan. 20 statement. DMHC said it receives complaints from managed care plan members having difficulty getting appointments with doctors, noting a 2009 study found that new patients in preferred provider organizations and health maintenance organizations wait an average of 59 days to see a family practice physician in Los Angeles. The adoption of the rules follows multiple rounds of public comment from managed care plans, providers, and consumers through most of last year. The state's Office of Administrative Law (OAL), which oversees regulatory agency rulemaking, rejected a previous version of the regulations issued Jan. 9, 2009, on the grounds that it provided too little time for public comment.

In March 2008, OAL also disapproved an earlier set of proposed rules after OAL concluded that by allowing plans to develop their own standards for patient wait times, they failed to comply with California administrative law requiring regulations to set uniform standard governing all plans.

Time Frames for Appointment Scheduling

The regulations require managed care plans meet the following appointment scheduling time frames:

1. urgent care appointments for services that do not require prior authorization within 48 hours of the request for appointment;
2. urgent care appointments for services that require prior authorization within 96 hours of the request for appointment;
3. non-urgent appointments for primary care within 10 business days of the request for appointment;
4. non-urgent appointments with specialist physicians within 15 business days of the request for appointment;
5. non-urgent appointments with a nonphysician mental health care provider within 10 business days of the request for appointment; and
6. non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition within 15 business days of the request for appointment.

However, the regulations permit these time frames to be extended if a provider has determined a longer waiting time will not have a detrimental impact on the health of the patient. The rules also contain an exception for non-urgent services including preventive care and periodic follow-up care.Plans must also provide 24/7 triage or screening services by telephone with wait times not exceeding 30 minutes.

Telephone triage or screening services can be provided through plan-operated telephonic triage or medical advice services, the plan's contracted primary care and mental health care provider network, or other means.