Dispute Resolution FAQs
1. What are the first steps a Managed Care Plan (MCP) and a Third-Party Entity should take if they have a dispute arising from the Memorandum of Understanding (MOU)?
If there is a dispute between an MCP and the Third-Party Entity, all parties are responsible for carrying out all their responsibilities under the MOU without delay, including providing Members with access to services under the MOU.
MCPs must work collaboratively with the Third-Party Entity to establish dispute resolution processes and timeframes which must be set forth in the MOU. The dispute resolution process should address how the MCP will work with the Third-Party Entity to resolve issues related to the parties’ respective roles for coverage and payment of services, and performance of care management for specific Members, or other concerns related to the administered services to Members. See the Base Template “Dispute Resolution” section for an example of the required language.
Information on specific Bespoke MOU Dispute resolution requirements can be found in the Questions Related to Specific Bespoke Templates section of the FAQs. Information on Dispute Resolution Process can be found in
APL 21-013 and
BHIN 21-034.
2. What if the MCP and Third-Party Entity fail to resolve the dispute internally?
If parties cannot resolve the dispute in good faith in accordance with their agreed upon process and timeframe established in the MOU, either party may submit a written “Request for Resolution” to the Department of Health Care Services (DHCS). The Third-Party Entity may submit the dispute to its oversight body (e.g., California Department of Publich Health (CDPH), the California Department of Social Services (CDSS), and the California Department of Developmental Services (CDDS)). If the MCP submits the Request for Resolution, it must be signed by the MCP’s Chief Executive Officer (CEO) or the CEO’s designee. If the Request for Resolution is submitted by the Third-Party Entity, it should be signed by an authorized representative of the Third-Party Entity. If the Third-Party Entity desires to review and sign off on any Request for Resolution submitted by the MCP, the parties should include this requirement in their executed MOU.
MCP’s Request for Resolution to DHCS must include:
- A summary of the disputed issue(s) and a statement of the desired remedies, including any disputed services that have been or are expected to be delivered to a Member;
- A history of the attempts to resolve the issue(s) with the Third-Party Entity;
- Justification for the desired remedy; and
- Any additional documentation relevant to resolve the disputed issue(s), if applicable, including documentation requested by DHCS or the Third Party’s oversight body.
Either party may submit the Request for Resolution to DHCS via secure email to
DHCS, in collaboration with the relevant department with oversight of the Third-Party Entity as appropriate, will communicate the final decision to the MCP and the Third-Party Entity, including any actions the MCP must take to implement the decision.
