DISCLAIMER: RevAssurance services do not constitute legal advice or legal consultation and do not establish an attorney-client relationship. The determination of the need for legal services and the choice of legal counsel are the sole responsibility of the Provider. You are encouraged to seek independent legal advice at your sole discretion.

ASK YOURSELF:

• What date was the claim initially billed?
• Was there any written communication (request for information, denial, underpayment) from the payor? IF SO, WHEN; HOW LONG AFTER THE CLAIM WAS BILLED?
• How many days is the plan in violation of the above prompt pay statute?
• Did they underpay the claim LATE, without the required statutory interest?
• Are we contracted with the plan? IF SO, WHAT IS THE EXPECTED REIMBURSEMENT?

The staff will be tactful and professional in communicating with the payor when making this firm call and request immediate compliance to the applicable code section:

Hi, my name is ____________________, this call may be recorded for compliance purposes, I’m calling to investigate a possible violation of 28 CCR §1300.71(g) can I give you a patient ID#?

This claim was billed on {BILL DATE} and is now {DAYS LATE} in violation of the statutory timeframes for prompt processing.  At this point, any contractual discounts have been forfeited and I have been asked to file a formal complaint with DMHC for full billed charges plus interest I am calling to help {PLAN OR IPA NAME} prevent any unnecessary regulatory action by adjudicating this claim today.

Are you authorized to issue a check today to bring your plan back into compliance?

REIMBURSEMENT TIMEFRAME:

Per, 28 CCR §1300.71(g):

A plan or a plan’s capitated provider shall reimburse each complete claim whether in state or out of state, as soon as practical, but no later than thirty (30) working days after the date of receipt of the complete claim by the plan or the plan’s capitated provider, or if the plan is a health maintenance organization, 45 working days after the date of receipt of the complete claim by the plan or the plan’s capitated provider, unless the complete claim or portion thereof is contested or denied, as provided in subdivision (h) (Emphasis added.)

Further, 28 CCR §1300.71(i) adds:

(1) Late payment on a complete claim for emergency services and care, which is neither contested nor denied, shall automatically include the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at the rate of 15 percent per annum for the period of time that the payment is late.

(2) Late payments on all other complete claims shall automatically include interest at the rate of 15 percent per annum for the period of time that the payment is late.

It is your obligation to ensure the continuous provision of quality healthcare to Knox-Keene enrollees, and comply with the prompt payment provisions of 28 CCR §1300.71(g) in order to indemnify the beneficiary enrollee for payment of any fees that are the legal obligation of the Knox Keene plan for services furnished by the provider.

DISCLAIMER:

I need to read you the following disclaimer: Your failure to reimburse {FACILITY NAME} is a serious matter and violates patient rights and state regulations 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 a request for audit, investigation and the assessment of sanction and penalties by the DMHC.