CA PPO 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 California Department of Insurance (CDI) for ’s failure to timely reimburse medically necessary services as required by state law.

Comment from the editor:

FOR NON-ER CLAIMS, ADD THIS BLURB TO YOUR DOWNLOADED LETTER:

Prompt reimbursement of a claim is defined under Cal. Ins. Code §10123.13(a), which states:

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.

Further, Cal. Ins. Code §10123.13(b) adds:

If an uncontested claim is not reimbursed by delivery to the claimant’s address of record within 30 working days after receipt, interest shall accrue and shall be payable at the rate of 10 percent per annum beginning with the first calendar day after the 30-working day period.

Comment from the editor:

FOR ER CLAIMS, ADD THIS BLURB TO YOUR DOWNLOADED LETTER:

Prompt reimbursement of a claim is defined under Cal. Ins. Code §10123.147(a), which states:

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.

Further, Cal. Ins. Code §10123.147(b) adds:

If a complete claim, or portion thereof, that is neither contested nor denied, is not reimbursed by delivery to the claimant’s address of record within the 30 working days after receipt, the insurer shall pay the greater of fifteen dollars ($15) per year or interest at the rate of 10 percent per annum beginning with the first calendar day after the 30-working day period.  An insurer shall automatically include the fifteen dollars ($15) per year or interest due in the payment made to the claimant, without requiring a request therefor.

As you are aware, is required to issue written notice if a claim or a portion is denied and state the specific reason for the denial. Further, this notice must also contain a statement with instructions to enter into a dispute resolution process per Cal. Ins. Code §10123.147(a). To date, we have not received any written correspondence or EOB regarding this claim’s denial.

Comment from the editor:

In the next paragraph below, you may switch “Cal. Ins. Code §10123.13(a)” with “Cal. Ins. Code §10123.147(a)” if you are using this letter for an ER Claim.

Under these circumstances, it is your obligation to ensure the continuous provision of quality healthcare to enrollees, and comply with the prompt payment provisions of Cal. Ins. Code §10123.13(a) in order to indemnify the insured for payment of any fees that are the legal obligation of the health plan for services furnished by providers that do not contract, or that have not otherwise entered into an agreement with the health plan, to provide services to the organization’s insured.

Comment from the editor:

In the next paragraph below, you may switch “Cal. Ins. Code §10123.13(b)” with “Cal. Ins. Code §10123.147(b)” if you are using this letter for an ER Claim.

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 California 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.

 

Respectfully,

 


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