Access for Infants and Mothers Program Banner

Health Plan's Dispute Resolution Process

If you are unhappy with something your health plan did (or did not do), you must resolve your problems with the plan according to its policies and procedures. The procedures are listed in the Evidence of Coverage (EOC) or Certificate of Insurance (COI) booklet. You will receive these booklets from the health plan. You may review these documents prior to selecting a health plan. Call the plan directly and ask for a copy.

If you are unable to resolve your dispute with the plan, and your insurance plan is licensed by the state, contact the state government agency, Department of Managed Health Care or Department of Insurance which licenses the insurance plan. The number is listed in the EOC or COI booklet.

What is Binding Arbitration?

Binding Arbitration is an agreement between some insurance plans and subscribers to have health care disputes reviewed by a neutral person. If you choose an insurance plan with arbitration, you give up the right to a jury or court trial to resolve disputes you may have with your insurance plan. The neutral person makes a decision after reviewing and hearing all the facts from both parties. Both parties agree to accept the decision.

Which plans require their members to use Binding Arbitration to resolve disputes?

  • Anthem Blue Cross EPO and HMO: Yes (includes medical malpractice)
  • CenCal Health's Santa Barbara Prenatal Plus 2: Yes (includes medical malpractice)
  • Central California Alliance for Health: No
  • Contra Costa Health Plan: No
  • Health Plan of San Joaquin: Yes (includes medical malpractice)
  • Kaiser Permanente: Yes (includes medical malpractice)
  • Ventura County Health Care Plan HMO: Yes (includes medical malpractice)