CA HMO Affidavit – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
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
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
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 – No Contract Underpayment
Last Updated: November 19, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Expected Reimbursement for Non-Contracted Claims — Gould Factors 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... View more
CA HMO Affidavit – Non-emergent Denial
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
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 – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
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 Knox-Keene Plan or Contracted Entity has met the provisions of... View more
CA HMO Affidavit – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
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
CA HMO Affidavit – Overpayment Offset
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Overpayment Offset 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(d)(6), which states: A plan... View more
CA HMO Affidavit – Patient Not Eligible
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
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 Knox-Keene Plan or Contracted Entity has met the provisions of Health and Safety Code §1371.8, which... View more
CA HMO Affidavit – Poststabilization Timeframe
Last Updated: October 8, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Poststabilization Care 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 28 CCR §1300.71.4(b)(2-3), which states: (2)... View more
CA HMO Affidavit – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Refund 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 Knox-Keene Plan or Contracted Entity has met the provisions of Health and Safety Code §1371.1(a)(1) and 28... View more