28 CCR §1300.71(e)(6-8)
August 28, 2020 5:40 pm(6) The plan’s contract with a claims processing organization or the capitated provider shall include provisions authorizing the plan to... View more
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28 CCR §1300.71(b)(3)
August 28, 2020 5:38 pm(b)(3) If a claim is sent to the plan’s capitated provider and the plan is responsible for adjudicating the claim,... View more
28 CCR §1300.71(b)(2)(B)
August 28, 2020 5:38 pm(2) If a claim is sent to a plan that has contracted with a capitated provider that is responsible for... View more
28 CCR §1300.71(b)(2)(A)
August 28, 2020 5:36 pm(2) If a claim is sent to a plan that has contracted with a capitated provider that is responsible for... View more
CA Evidence Code §641
August 28, 2020 5:33 pmA letter correctly addressed and properly mailed is presumed to have been received in the ordinary course of mail.
28 CCR §1300.71(a)(6)
August 28, 2020 5:32 pm(a)(6): “Date of receipt” means the working day when a claim, by physical or electronic means, is first delivered to... View more
28 CCR §1300.71(a)(3)(A)
August 28, 2020 5:32 pm(A) For contracted providers with a written contract, including in-network point-of-service (POS) and preferred provider organizations (PPO): the agreed upon... View more
Health & Safety Code 1371.37(c)(2)
August 28, 2020 5:31 pm(C) “An ‘unfair payment pattern,’ as used in this section means any of the following: (2) Engaging in a demonstrable... View more
28 CCR §1300.71(3)(B)
August 28, 2020 5:30 pm(B) For contracted providers without a written contract and non-contracted providers, except those providing services described in paragraph (C) below:... View more
California’s Notice-Prejudice Rule
August 28, 2020 5:30 pm“[A] defense based on an insured’s failure to give timely notice [of a claim] requires the insurer to prove that... View more