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
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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
28 CCR §1300.71(b)(4)
August 28, 2020 5:29 pm(4) A plan or a plan’s capitated provider that denies a claim because it was filed beyond the claim filing... View more
28 CCR §1300.71(b)(1)
August 28, 2020 5:28 pm(1) Neither the plan nor the plan’s capitated provider that pays claims shall impose a deadline for the receipt of... View more
28 CCR §1300.71(g)
August 28, 2020 5:13 pm(g) A plan or a plan’s capitated provider shall reimburse each complete claim whether in state or out of state,... View more
28 CCR §1300.71.4(b)
August 28, 2020 5:12 pm(b) In the case when an enrollee is stabilized but the health care provider believes that the enrollee requires additional... View more
Health and Safety Code §1371.8
August 28, 2020 5:11 pmA health care service plan that authorizes a specific type of treatment by a provider shall not rescind or modify... View more
28 CCR §1300.71(b)(5)
August 28, 2020 5:11 pm(5) A plan or a plan’s capitated provider shall not request reimbursement for the overpayment of a claim, including requests... View more
Health and Safety Code §1371.1(a)(1)
August 28, 2020 5:10 pm(a)(1) Whenever a health care service plan, including a specialized health care service plan, determines that in reimbursing a claim for... View more