CA Medi-Cal Appeal – ETAR Authorization Timeframe
Last Updated: September 3, 2020 | Letter Type: Appeals | Jurisdiction: Medi-Cal
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Department of Health Care Services (DHCS) for ’s failure to meet the timeframe and notice requirements for non-urgent authorization requests as required by State law. Our investigation has concluded the following: THIS REQUEST IS NOW DAYS IN... View more
CA Medi-Cal Fax Cover Sheet – COHS Request for Authorization
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: Medi-Cal
REQUEST FOR AUTHORIZATION At this time, we are requesting authorization to render treatment to your insured. : California law requires that you cover and reimburse all emergency medical services without prior authorization, per 22 CCR § 53855(a). Where a medical screening examination indicates that the patient’s condition does... View more
CA PPO Affidavit – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Interest Owed on Late Claims 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... View more
CA PPO Affidavit – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Medical Necessity 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 §10123.135(e), which states: (e) An... View more
CA PPO Affidavit – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Emergency and Urgently Needed Services 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 §10112.7(a)(1)... View more
CA PPO Affidavit – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Timeframes for Authorization Requests – Non-Urgent Health Services 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.... View more
CA PPO Affidavit – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Notice Requirements for Adverse Determinations 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 §10123.135(h)(4),... View more
CA PPO Affidavit – Patient Not Eligible
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Patient Not Eligible 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 Insurer or Contracted Entity has met the provisions of Cal. Ins. Code §796.04 and Cal. Ins.... View more
CA PPO Affidavit – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Recoupment 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 §10123.145(a)(1) and Cal. Ins. Code... View more
CA PPO Affidavit – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Retroactive Denial of Authorized Services 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 §796.04,... View more