AFFIDAVIT OF COMPLIANCE

Prompt Payment to Providers

Incorporated by Reference in 28 US Code § 1746

Patient/Multiple Patients:         DOS:

I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Knox-Keene Plan or Contracted Entity has met the provisions of 28 CCR §1300.71(g), which states:

A plan or a plan’s capitated provider shall reimburse each complete claim whether in state or out of state, as soon as practical, but no later than thirty (30) working days after the date of receipt of the complete claim by the plan or the plan’s capitated provider, or if the plan is a health maintenance organization, 45 working days after the date of receipt of the complete claim by the plan or the plan’s capitated provider, unless the complete claim or portion thereof is contested or denied, as provided in subdivision (h) (Emphasis added).

I fully understand that claims paid beyond the above statutory timeframes must include automatic interest pursuant to 28 CCR §1300.71(i).

I fully understand that this affidavit constitutes an official statement under penalty of perjury under the laws of the United States subject to possible audit and investigation by the State of California.

 

Knox-Keene Plan:

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Knox-Keene Plan Representative Signature:

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Knox-Keene Plan Representative Title:

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Date:

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