28 CCR §1300.71(b)(2)(B)

August 28, 2020 5:38 pm Published by

(2) If a claim is sent to a plan that has contracted with a capitated provider that is responsible for adjudicating the claim, then the plan shall do the following:

(B) For a provider claim that does not involve emergency service or care:

(i) if the provider that filed the claim is contracted with the plan’s capitated provider, the plan within ten (10) working days of the receipt of the claim shall either:

(1) send the claimant a notice of denial, with instructions to bill the capitated provider or

(2) forward the claim to the appropriate capitated provider;

(ii) in all other cases, the plan within ten (10) working days of the receipt of the claim incorrectly sent to the plan shall forward the claim to the appropriate capitated provider.

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