28 CCR §1300.71(e)(6-8)

August 28, 2020 5:40 pm Published by

(6) The plan’s contract with a claims processing organization or the capitated provider shall include provisions authorizing the plan to assume responsibility for the processing and timely reimbursement of provider claims in the event that the claims processing organization or the capitated provider fails to timely and accurately reimburse its claims (including the payment of interest and penalties). The plan’s obligation to assume responsibility for the processing and timely reimbursement of a capitated provider’s provider claims may be altered to the extent that the capitated provider has established an approved corrective action plan consistent with section 1375.4(b)(4) of the Health and Safety Code. (Emphasis added.)

(7) The plan’s contract with the capitated provider shall include provisions authorizing a plan to assume responsibility for the administration of the capitated provider’s dispute resolution mechanism(s) and for the timely resolution of provider disputes in the event that the capitated provider fails to timely resolve its provider disputes including the issuance of a written decision. (Emphasis added.)

(8) The plan’s contract with a claims processing organization or a capitated provider shall not relieve the plan of its obligations to comply with sections 1371, 1371.1, 1371.2, 1371.22, 137l.35, 1371.36, 1371.37, 1371.4, and 1371.8 of the Health and Safety Code and sections 1300.71, 1300.71.38, 1300.71.4, and 1300.77.4 of title 28.

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