CA PPO Affidavit – Untimely Filing
Last Updated: November 22, 2021 | Letter Type: Affidavits | Jurisdiction: CA PPO
AFFIDAVIT OF COMPLIANCE Denial of Timely Billed 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 §10133.66(a),... View more
CA PPO Appeal – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: CA PPO
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 remit automatic interest accrued on this claim as required by State law. Our investigation has concluded the following: Cal. Ins. Code §§10123.13 and 10123.147 (a) states: Every... View more
CA PPO Appeal – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: CA PPO
IMPERATIVE-ACTION REQUIRED 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 services as required by state law. Our investigation has concluded the following: Please be advised, Cal. Ins. Code §10123.135(e) states: An individual, other than a... View more
CA PPO Appeal – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: CA PPO
IMPERATIVE-ACTION REQUIRED 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 emergency services as required by state law. Our investigation has concluded the following: Cal. Ins. Code §10112.7(b)(1) defines “emergency services and care” as: A medical screening examination that... View more
CA PPO Appeal – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: CA PPO
IMPERATIVE-ACTION REQUIRED 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 services as required by state law. Our investigation has concluded the following: THIS REQUEST IS NOW DAYS IN VIOLATION OF THE STATUTORY TIMEFRAMES. Under existing... View more
CA PPO Appeal – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: CA PPO
IMPERATIVE-ACTION REQUIRED 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 services as required by state law. Our investigation has concluded the following: On , denied this claim as not medically necessary. To date, we have... View more
CA PPO Appeal – Patient Not Eligible
Last Updated: August 29, 2020 | Letter Type: Appeals | Jurisdiction: CA PPO
IMPERATIVE-ACTION REQUIRED 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 services as required by state law. Our investigation has concluded the following: To expedite this matter and foreclose any further argument, I draw your attention... View more
CA PPO Appeal – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: CA PPO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the California Department of Insurance (CDI) for ’s failure to properly reimburse medically necessary services as required by state law. Our investigation has concluded the following: Please be advised that must meet the written requirements set forth in... View more
CA PPO Appeal – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: CA PPO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Department of Insurance (CDI) for ’s failure to reimburse authorized health services as required by State law. Our investigation has concluded the following: On , authorization number was issued by . Please be advised Cal. Ins. Code... View more
CA PPO Appeal – Untimely Filing
Last Updated: September 3, 2020 | Letter Type: Appeals | Jurisdiction: CA PPO
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 reimburse medically necessary services as required by state law. Our investigation has concluded the following: [SCENARIO 1: CLAIM WAS TIMELY FILED] Please be advised that Cal. Ins.... View more