CA HMO Script – Maternity Coverage

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  • Did we verify eligibility? IF SO, WHAT DATE?
  • Did the plan make negligent misrepresentation of the patient’s eligibility?
  • Did the plan deny maternity coverage for no authorization?
  • Is the plan refusing to comply with Health and Safety Code §1367.62(a)?

The objective is to bring the plan into compliance with state law designed to benefit the public and protect our financial viability.

Hi, my name is ____________________, this call may be recorded for compliance purposes, I’m calling to investigate a possible violation of Health and Safety Code §1367.62(a) can I give you a patient ID#?



Pursuant to Health and Safety Code §1367.62(a)(7), no health care service plan should:

Require the treating physician to obtain authorization from the health care service plan prior to prescribing any services covered by this section

Further, under Health and Safety Code §1367.62(a), {PAYOR} has a duty to provide all Maternity-covered services and is mandated by state law to cover these services. Health and Safety Code §1367.62(a) states:

(a) No health care service plan contract that is issued, amended, renewed, or delivered on or after the effective date of the act adding this section, that provides maternity coverage, shall do any of the following:

(1) Restrict benefits for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following a delivery by caesarean section.  However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours if both of the following conditions are met:

(A) The decision to discharge the mother and newborn before the 48- or 96-hour time period is made by the treating physicians in consultation with the mother.

(2) Reduce or limit the reimbursement of the attending provider for providing care to an individual enrollee in accordance with the coverage requirements.

I urge you to adjudicate this claim today to bring your plan back into compliance.  As mandated by the applicable statutory law, we request that you reevaluate your position in this matter and urge you to take appropriate steps, to rectify the problem and demonstrate your good faith in this matter.

When is your next check run?  I need to track the compliance of your plan regarding this matter.


I need to read you the following disclaimer: Your failure to reimburse {FACILITY NAME} is a serious matter and violates patient rights and state regulation designed to benefit the public (UNTIMELY PAYMENT HAS A NEGATIVE EFFECT ON LEVEL OF CARE).

The provision of continuous quality health care in our region depends on {FACILITY NAME} receiving payment for medically necessary services provided to patients.

Failure to comply with this telephonic notification of non-compliance to the applicable code section may result in audit, investigation and the assessment of sanction and penalties by the DMHC.