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 – COB Denial
Last Updated: August 29, 2020 | 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 attempt to improperly enforce their right to subrogation or coordination of benefits. Our investigation has concluded the following: Please be advised, the claim is beyond the time frame... View more
CA HMO Appeal – Concurrent Disagreement of Care
Last Updated: August 29, 2020 | Letter Type: Appeals | Jurisdiction: CA HMO
IMPERATIVE-ACTION REQUIRED 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 reimburse emergency services as required by State law. Per your request, we can provide you the following below checked items at this time: Factsheet of Admission Discharge... View more