Form CSD-004 "Health Care Provider Request for Assistance (Hprfa)" - California

What Is Form CSD-004?

This is a legal form that was released by the California Department of Insurance - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 7, 2019;
  • The latest edition provided by the California Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CSD-004 by clicking the link below or browse more documents and templates provided by the California Department of Insurance.

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Download Form CSD-004 "Health Care Provider Request for Assistance (Hprfa)" - California

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STATE OF CALIFORNIA
Ricardo Lara, Insurance Commissioner
DEPARTMENT OF INSURANCE
HEALTH CLAIMS BUREAU
300 SOUTH SPRING STREET, SOUTH TOWER
LOS ANGELES, CA 90013
www.insurance.ca.gov
CSD-004
Eff. 01/07/2019
HEALTH CARE PROVIDER REQUEST FOR ASSISTANCE (HPRFA)
Patient’s
Patient’s Name:
Patient’s Gender: M
F
Date of Birth:
Provider Contact Name (Last, First):
Provider/Facility Name:
Provider Address:
City:
Zip:
Phone Number:
E-mail Address:
Before you file for a case review with the Department of Insurance, you should first exhaust the
Dispute Resolution (DR) process with the insurance company. The insurer is required to resolve each
provider dispute consistent with applicable law and issue a written determination within 45 working
days after the date of receipt of the provider dispute.
To ensure proper review of the case, a copy of the completed Health Care Provider Request for
Assistance form and other documentation submitted by you will be provided to the insurance
company, agent or the broker.
Primary policyholder’s name if different than the patient:
Patient’s primary language spoken at home:
In order to ensure all Californians have access to health insurance, please identify patient’s race/ethnicity.
One or more categories may be selected:
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Pacific Islander/Native Hawaiian
White
Decline to State
Complete name of insurance company involved:
Type of Insurance:
Individual Health
Group Health
Dental
Vision
Medicare Supp
Do you have an existing contract with the insurance company? Yes
(Provide copy)
No
Have you contacted the insurance company and exhausted the Internal Dispute Resolution Process?
Yes
(Provide copies of all correspondence)
No
Were services rendered in an in-network facility? Yes
No
Were services related to emergency care? Yes
No
Claim Number:
Policy/Certificate/ID Number:
Group Name:
Group Number:
Page 1 of 2
STATE OF CALIFORNIA
Ricardo Lara, Insurance Commissioner
DEPARTMENT OF INSURANCE
HEALTH CLAIMS BUREAU
300 SOUTH SPRING STREET, SOUTH TOWER
LOS ANGELES, CA 90013
www.insurance.ca.gov
CSD-004
Eff. 01/07/2019
HEALTH CARE PROVIDER REQUEST FOR ASSISTANCE (HPRFA)
Patient’s
Patient’s Name:
Patient’s Gender: M
F
Date of Birth:
Provider Contact Name (Last, First):
Provider/Facility Name:
Provider Address:
City:
Zip:
Phone Number:
E-mail Address:
Before you file for a case review with the Department of Insurance, you should first exhaust the
Dispute Resolution (DR) process with the insurance company. The insurer is required to resolve each
provider dispute consistent with applicable law and issue a written determination within 45 working
days after the date of receipt of the provider dispute.
To ensure proper review of the case, a copy of the completed Health Care Provider Request for
Assistance form and other documentation submitted by you will be provided to the insurance
company, agent or the broker.
Primary policyholder’s name if different than the patient:
Patient’s primary language spoken at home:
In order to ensure all Californians have access to health insurance, please identify patient’s race/ethnicity.
One or more categories may be selected:
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Pacific Islander/Native Hawaiian
White
Decline to State
Complete name of insurance company involved:
Type of Insurance:
Individual Health
Group Health
Dental
Vision
Medicare Supp
Do you have an existing contract with the insurance company? Yes
(Provide copy)
No
Have you contacted the insurance company and exhausted the Internal Dispute Resolution Process?
Yes
(Provide copies of all correspondence)
No
Were services rendered in an in-network facility? Yes
No
Were services related to emergency care? Yes
No
Claim Number:
Policy/Certificate/ID Number:
Group Name:
Group Number:
Page 1 of 2
Date(s) of Medical Service(s) Provided:
CPT Codes:
Does the complaint concern the payment of a specific claim? Yes
No
If yes, provide: Billed Amount $ ________
Paid Amount $_________
Amount in Dispute $_________
Have you reported this to any other governmental agency?
Yes
No
Name of agency: ___________________________ File number, if known: _____________________
Have you previously written to the Department of Insurance about this matter?
Yes
No
File number (if available) _____________________
Are you represented by an attorney in this matter? Yes
No
Is the case currently in active litigation? Yes
No
If yes, we will defer the regulatory investigation until the finality of the litigation. We ask that you still complete
this form so we have a record of your issue. Once the matter is concluded, we would welcome any information
regarding violations of insurance law by the insurer that you or your attorney are willing to provide.
Briefly describe the disputed issue. Use additional paper as needed.
The following documents must accompany this form. Failure to provide all or any part of the information
requested may preclude or delay the Consumer Services Division of the Department of Insurance from
reviewing your complaint.
Copy of the patient’s (signed) Assignment of Benefits, if applicable
Copy of claim forms submitted to the insurance company (UB 92, HCFA 1500, etc.)
Copies of all correspondence between the provider and the insurance company, including all
related EOBs
Copy of the Dispute Resolution Process determination letter
Copy of the patient’s insurance identification card – both sides
Copy of the provider’s contract with the insurance company, if any
Copy of the Internal Dispute Resolution Process determination letter
________________________________
______________________________
Provider’s Signature
Date
Page 2 of 2
Ricardo Lara, Insurance Commissioner
STATE OF CALIFORNIA
DEPARTMENT OF INSURANCE
Privacy Notice on Information Collection
Request for Assistance Forms
*** This notice is provided pursuant to the Information Practices Act of 1977 (California Civil Code Section 1798.17) ***
Collection and Use of Personal Information
California Insurance Code Sections 12921 and 12921.1, and related statutes and regulations, give the
California Department of Insurance (CDI) and the Consumer Services Division the authority to regulate and
investigate consumer complaints. The CDI uses your information to address complaints brought to the
Department’s attention. Information is collected subject to limitations contained in the Information Practices Act
of 1977, SAM 5300, et seq., SIMM 5305, et seq., and other applicable state and federal laws.
Providing Personal Information Is Voluntary
You do not have to provide the personal information requested. However, if you do not wish to provide us the
necessary information, we may not be able to investigate your complaint. When providing information or
documents, please do not include unrequested personal information, such as Social Security Numbers,
Driver’s License Numbers, unnecessary health-related information, and credit card or financial information.
Information Provided to CDI Is Confidential
All information you provide to us during the investigation of your complaint will be treated as a confidential
communication under California Insurance Code Section 12919. We will not disclose any information to any
person outside CDI, unless otherwise permitted or required by law.
Possible Disclosure of Personal Information
We may share your personal information with the insurance licensee and in the case of an Independent Medical
Review with the Independent Medical Review Organization. We may also share your information with other
government agencies as required by law.
Access to Your Information
You have the right to access records containing your personal information which are maintained by CDI. To
request access, contact: CDI Privacy Officer, Legal Division, Government Law Bureau, 300 Capitol Mall,
Suite 1700, Sacramento, CA 95814, (916) 492-3500.
Department Privacy Policy
The California Department of Insurance has developed policies regarding the privacy of your information. They
may be viewed at www.insurance.ca.gov/privacy-policy.
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