State IDR guide
California Independent Dispute Resolution Guide
Department of Managed Health Care and California Department of Insurance
California has a bifurcated state/federal environment. AB 72 processes can govern specified nonemergency services by noncontracting professionals at contracting facilities; regulator and product jurisdiction matter.
Plan and jurisdiction considerations
Identify whether DMHC or CDI regulates the product and whether the service falls within the state statute. Federal IDR generally remains relevant to ERISA self-funded coverage and claims outside a controlling state payment method.
Federal fallback
Use Federal IDR only after confirming that a specified California law does not determine the out-of-network rate for the claim.
Timing and fees
AB 72 requires completion of the payer's provider dispute process and uses regulator-specific filing instructions. DMHC states that qualifying PDR determinations must generally have been completed within the last 365 days. Verify current forms, deadlines, and any fee before filing.
Air ambulance considerations
Air ambulance payment disputes are generally routed through Federal IDR when federally eligible; confirm no controlling exception for the plan and claim.