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
CA HMO Appeal – Untimely Filing
Last Updated: August 28, 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 timely billed health services as required by state law. Our investigation has concluded the following: [SCENARIO 1: CLAIM WAS TIMELY FILED] Please be advised that... View more
CA HMO Appeal – Untimely Filing with Exceptional Circumstance
Last Updated: September 5, 2020 | Letter Type: Appeals | Jurisdiction: CA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of Claims: 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 for untimely filing. However, did not provide... View more
CA HMO Fax Cover Sheet – General Ambulance Transport Appeal
Last Updated: December 29, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: CA HMO
REQUEST FOR RECONSIDERATION We believe you have failed to comply for the following reasons: Related laws: California Health & Safety Code § 1367.01, California Insurance Code § 10123.135, and 28 CCR § 1300.71(e) Related laws: California Health & Safety Code § 1367.01 and California Health & Safety Code §... View more
CA HMO Fax Cover Sheet – General Ambulance Transport Request for Authorization
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: CA HMO
REQUEST FOR AUTHORIZATION At this time, we are requesting authorization to provide transportation services to your insured. : California allows health care service plans to establish written policies and procedures for authorization requests to provide services for plan enrollee, per California Health & Safety Code § 1367.01 and California... View more
CA HMO Fax Cover Sheet – Notification of Disagreement of Care
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: CA HMO
NOTIFICATION OF DISAGREEMENT OF CARE On , you notified our facility that further post-stabilization care was denied. This notice serves as a formal NOTICE OF DISAGREEMENT OF CARE. : Federal regulations mandate that you are financially responsible for post-stabilization care services until (1) a plan physician with privileges... View more
CA HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: CA HMO
REQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1) provide post-stabilization authorization, or (2) enter into a disagreement of care and arrange for the transfer of the patient within 60 minutes from receipt of this notification, per 42 CFR §422.113. Please be advised that... View more
CA Medi-Cal Affidavit – ETAR Authorization Timeframes
Last Updated: December 30, 2024 | Letter Type: Affidavits | Jurisdiction: Medi-Cal
AFFIDAVIT OF COMPLIANCE Timeframes for ETAR Authorization Requests 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 Medi-Cal has met the provisions of Welfare & Institutions Code §14133.9(d), which states: (d) When a proposed... View more