CA HMO Appeal – Timely Payment

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URGENT- IMPERATIVE ACTION

Dear Director of :

This office has been asked to file a formal complaint with the Department of Managed Health Care (DMHC) for ’s failure to timely reimburse this claim as required by State law.

Prompt reimbursement of a claim is defined under 28 CCR §1300.71(g):

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).

Further, 28 CCR §1300.71(i) adds:

(1) Late payment on a complete claim for emergency services and care, which is neither contested nor denied, shall automatically include the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at the rate of 15 percent per annum for the period of time that the payment is late.

(2) Late payments on all other complete claims shall automatically include interest at the rate of 15 percent per annum for the period of time that the payment is late.

Under these circumstances, it is your obligation to ensure the continuous provision of quality healthcare to Knox-Keene enrollees, and comply with the prompt payment provisions of Sec. 1300.71(g)  in order to indemnify the enrollee for payment of any fees that are the legal obligation of the Knox-Keene plan for services furnished by providers that do not contract, or that have not otherwise entered into an agreement with the Knox-Keene plan, to provide services to the organization’s beneficiary enrollees.

We hereby demand immediate payment of the above referenced claim(s) plus interest pursuant to 28 CCR §1300.71(i).  Should you fail to remit payment to the undersigned within ten (10) days, be advised that we may draft a formal complaint to the Department of Managed Health Care (DMHC) to ensure our rights under state law are preserved.

Please make any further action on our part unnecessary, by remitting payment in full immediately.

 

Respectfully,

 


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