CA HMO Appeal – Contract Underpayment
Last Updated: November 19, 2021 | 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 State law. Our investigation has concluded the following: We are contracted with and, accordingly, must comply with the below... View more
CA HMO Appeal – Interest Owed on Late Claims
Last Updated: November 21, 2021 | 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 remit automatic interest accrued on this claim as required by State law. Our investigation has concluded the following: Prompt reimbursement of a claim is defined under... View more
CA HMO Appeal – LA City Ambulance Transport No Contract Underpayment
Last Updated: November 19, 2021 | 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 State law. Our investigation has concluded the following: As you know, there is no established contract between and for... View more
CA HMO Appeal – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | 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 medically necessary services as required by State law. Our investigation has concluded the following: Please be advised that our treating physician was a . However, your... View more
CA HMO Appeal – Misdirected Claims
Last Updated: October 22, 2021 | 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 medically necessary services as required by State law. Our investigation has concluded the following: [SCENARIO 1: CLAIM FOR ER SERVICES SENT TO HEALTH PLAN INSTEAD OF... View more
CA HMO Appeal – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | 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. Our investigation has concluded the following: Health and Safety Code §1317.1 (a) defines “emergency services and care” as: …Medical screening,... View more
CA HMO Appeal – No Claim on File
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 failure to safeguard and process the claim, as required by state law. This claim was billed on and not rejected. On , we called , and spoke to... View more
CA HMO Appeal – No Contract Underpayment
Last Updated: November 19, 2021 | 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 State law. Our investigation has concluded the following: [SCENARIO 1: HMO PAYOR- Pay per UCR] As you know,... View more
CA HMO Appeal – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | 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 meet the timeframe and notice requirements for non-urgent authorization requests as required by State law. Our investigation has concluded the following: THIS REQUEST IS NOW DAYS IN... View more
CA HMO Appeal – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | 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 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... View more