CA PPO Appeal – Maternity Coverage

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Dear Director of :

This office has been asked to file a formal complaint with the California Department of Insurance (CDI) for ’s failure to reimburse medically necessary maternity services as required by state law.

Our investigation has concluded the following:

Under existing state law, has a duty to provide all Maternity-covered services and is mandated by state law to cover these services. Cal. Ins. Code §10123.87(a) states:

(a) No individual or group policy of disability insurance that provides coverage for hospital, medical, and surgical benefits that is issued, amended, renewed, or delivered on or after the effective date of the act adding this section, that provides maternity coverage, shall do any of the following:

(1) Restrict benefits for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following a delivery by caesarean section.  However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours if both of the following conditions are met:

(A) The decision to discharge the mother and newborn before the 48- or 96-hour time period is made by the treating physicians in consultation with the mother.

(2) Reduce or limit the reimbursement of the attending provider for providing care to an individual insured in accordance with the coverage requirements.

(7) Require the treating physician to obtain authorization from the insurer prior to prescribing any services covered by this section.

Here, failed to comply with Cal. Ins. Code §10123.87(a). Upon the provider rendering maternity services to the patient, became financially liable for these services because the services are covered under Ca. Ins. Code §10123.87(a) and do not require prior-authorization.

We hereby demand immediate payment of the above referenced claim(s) plus interest pursuant to Cal. Ins. Code §10123.13(b).  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 Insurance (CDI) to ensure our rights under state law are preserved.

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




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