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Found 373 Letters.

CA HMO Affidavit – Maternity (FREE DEMO)

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

AFFIDAVIT OF COMPLIANCE Maternity 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 Knox-Keene Licensed Plan or Contracted Entity has met the provisions of Health and Safety Code §1367.62(a) which... View more

CA HMO Affidavit – Good Cause for Untimely Billed Claims

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: September 5, 2020

AFFIDAVIT OF COMPLIANCE Good Cause for Untimely 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 Knox-Keene Plan or Contracted Entity has met the provisions of 28 CCR §1300.71(b)(1)... View more

CA HMO Affidavit – Interest Owed

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

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 Knox-Keene Plan or Contracted Entity has met the provisions of 28 CCR §1300.71(i), which... View more

CA HMO Affidavit – LA City Underpaid Non-Contracted Ambulance Transport

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

AFFIDAVIT OF COMPLIANCE Expected Reimbursement for L.A. City Non-Contracted Ambulance Transport 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 Knox-Keene Plan or Contracted Entity has met the provisions of... View more

CA HMO Affidavit – Med Nec Qualified Reviewer

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

AFFIDAVIT OF COMPLIANCE Medical Necessity Competent Reviewer 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 Knox-Keene Plan or Contracted Entity has met the provisions of Health and Safety Code §1370.2,... View more

CA HMO Affidavit – Misdirected Claims

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: October 22, 2021

AFFIDAVIT OF COMPLIANCE Misdirected Claim 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 Knox-Keene Licensed Plan or Contracted Entity has met the provisions of 28 CCR §1300.71(b)(2-3), which states: (2)... View more

CA HMO Affidavit – No Auth for ER

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

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 Knox-Keene Plan or Contracted Entity has met the provisions of Health and Safety Code... View more

CA HMO Affidavit – No Claim on File

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

AFFIDAVIT OF COMPLIANCE No Claim on File 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 Knox-Keene Plan or Contracted Entity has met the provisions of 28 CCR §1300.71(a)(6) and CA... View more

CA HMO Affidavit – Non-emergent Denial

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

AFFIDAVIT OF COMPLIANCE Denial of Emergency 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 Knox-Keene Plan or Contracted Entity has met the provisions of Health & Safety Code §1317(a),... View more

CA HMO Affidavit – Notice Requirements

Letter Type: Affidavits | Jurisdiction: CA HMO | Last Updated: August 29, 2020

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 Knox-Keene Plan or Contracted Entity has met the provisions of Health and Safety Code... View more