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 Health Insurer or Contracted Entity has met the provisions of Cal. Ins. Code §10123.13(a) and Cal. Ins. Code §10123.147(a), which states:

Cal. Ins. Code §10123.13(a):

Every insurer issuing group or individual policies of health insurance that covers hospital, medical, or surgical expenses, including those telehealth services covered by the insurer as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code , shall reimburse claims or any portion of any claim, whether in state or out of state, for those expenses as soon as practical, but no later than 30 working days after receipt of the claim by the insurer unless the claim or portion thereof is contested by the insurer, in which case the claimant shall be notified, in writing, that the claim is contested or denied, within 30 working days after receipt of the claim by the insurer.

Cal. Ins. Code §10123.147(a):

Every insurer issuing group or individual policies of health insurance that covers hospital, medical, or surgical expenses, including those telehealth services covered by the insurer as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code , shall reimburse each complete claim, or portion thereof, whether in state or out of state, as soon as practical, but no later than 30 working days after receipt of the complete claim by the insurer.  However, an insurer may contest or deny a claim, or portion thereof, by notifying the claimant, in writing, that the claim is contested or denied, within 30 working days after receipt of the complete claim by the insurer.

I fully understand that claims paid beyond the above statutory timeframes must include interest pursuant to Cal. Ins. Code §10123.13(b) or Cal. Ins. Code §10123.147(b).

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.

 

Health Insurer:

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Health Insurer Representative Signature:

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Health Insurer Representative Title:

_________________________________________________

 

Date:

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