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
CA HMO Affidavit – Request for Insignificant Information
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Request for Insignificant Information 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)(10), which states:... View more
CA HMO Affidavit – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
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 Knox-Keene Plan or Contracted Entity has met the provisions of Health and Safety Code... View more
CA HMO Affidavit – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Retroactive Denial Trend 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 §1371.8 and... View more
CA HMO Affidavit – Silent PPO
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Silent PPO – Non-existent Contract 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 California Business & Professions... View more
CA HMO Affidavit – Unauthorized Treatment
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Unauthorized Treatment 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 §1371.36(a), which states:... View more
CA HMO Affidavit – Uncontested Portion of Claim
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Denial of Uncontested Portion of 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 Plan or Contracted Entity has met the provisions of Health & Safety... View more
CA HMO Affidavit – Untimely Filing
Last Updated: August 29, 2020 | Letter Type: Affidavits | Jurisdiction: CA HMO
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 Knox-Keene Plan or Contracted Entity has met the provisions of 28 CCR §1300.71(b)(1) and... View more
CA HMO Affidavit – Untimely Filing with Exceptional Circumstance
Last Updated: November 30, 2021 | Letter Type: Affidavits | Jurisdiction: CA HMO
AFFIDAVIT OF COMPLIANCE Untimely Filing with Exceptional Circumstance 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 Valley View Home of... View more
CA HMO Appeal – Ambulance Transport Contract No Authorization Improper Notice
Last Updated: December 17, 2024 | Letter Type: Appeals | Jurisdiction: CA HMO
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Department of Managed Health Care (DMHC) for ’s failure to properly reimburse health services as required by California law. Our investigation has concluded the following: As you know, your capitated provider, , authorized and requested our... View more