CA HMO Appeal – Patient Not Eligible
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 medically necessary services as required by State law. Our investigation has concluded the following: To expedite this matter and foreclose any further argument, I draw your... View more
CA HMO Appeal – Poststabilization Timeframe
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 and/or statutorily authorized post-stabilization services and care as required by State law. Our investigation has concluded the following: TO DATE, HAS FAILED TO REIMBURSE EMERGENCY... View more
CA HMO Appeal – Refund Recoupment
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 properly reimburse medically necessary services as required by State law. Our investigation has concluded the following: Please be advised that must meet the written requirements set forth... View more
CA HMO Appeal – Request for Insignificant Information
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. It is our understanding that the above claim has not been paid pending your receipt of the additional information... View more
CA HMO Appeal – Retroactive Denial for Authorized 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 authorized health services as required by State law. Our investigation has concluded the following: On , authorization number was issued by . Please be advised Health... View more
CA HMO Appeal – Retroactive Denial Trend
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 authorized health services as required by State law. Our investigation has concluded the following: On , authorization number was issued by . Please be advised Health... View more
CA HMO Appeal – Silent PPO
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 access a non-existent contractual discount on this claim. Our investigation has concluded the following: Please be advised Business and Professions Code §511.1(c)(1) states: (c) Beginning July 1,... View more
CA HMO Appeal – Unauthorized Treatment
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. It has been brought to our attention that the claim remains denied, as unauthorized treatment. As such, this office... View more
CA HMO Appeal – Uncontested Portion of Claim 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 failure to reimburse the uncontested portion of the claim (e.g. emergency services). Our investigation has concluded the following: As you know, 28 CCR §1300.71(a) defines a complete claim... View more
CA HMO Appeal – Unlawful Offset
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 medically necessary services as required by State law. On , this office received a refund request and/or offset from your office that claimed (Check all that... View more