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 California Insurance Code §10123.13(a) or California Insurance Code §10123.147(a); 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 CDI 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 NON-ER CLAIMS:

California Insurance Code §10123.13(a) states:

Every insurer issuing group or individual policies of health insurance that covers hospital, medical, or surgical expenses, including those telehealth services covered by the insurer as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code , shall reimburse claims or any portion of any claim, whether in state or out of state, for those expenses as soon as practical, but no later than 30 working days after receipt of the claim by the insurer unless the claim or portion thereof is contested by the insurer, in which case the claimant shall be notified, in writing, that the claim is contested or denied, within 30 working days after receipt of the claim by the insurer.

Further, California Insurance Code §10123.13(b) adds:

If an uncontested claim is not reimbursed by delivery to the claimant’s address of record within 30 working days after receipt, interest shall accrue and shall be payable at the rate of 10 percent per annum beginning with the first calendar day after the 30-working day period.

REIMBURSEMENT TIMEFRAME ER CLAIMS:

California Insurance Code §10123.147(a) states:

Every insurer issuing group or individual policies of health insurance that covers hospital, medical, or surgical expenses, including those telehealth services covered by the insurer as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, shall reimburse each complete claim, or portion thereof, whether in state or out of state, as soon as practical, but no later than 30 working days after receipt of the complete claim by the insurer.  However, an insurer may contest or deny a claim, or portion thereof, by notifying the claimant, in writing, that the claim is contested or denied, within 30 working days after receipt of the complete claim by the insurer.

Further, California Insurance Code §10123.147(b) adds:

If a complete claim, or portion thereof, that is neither contested nor denied, is not reimbursed by delivery to the claimant’s address of record within the 30 working days after receipt, the insurer shall pay the greater of fifteen dollars ($15) per year or interest at the rate of 10 percent per annum beginning with the first calendar day after the 30-working day period.  An insurer shall automatically include the fifteen dollars ($ 15) per year or interest due in the payment made to the claimant, without requiring a request therefor.

It is your obligation to ensure the continuous provision of quality healthcare to enrollees, and comply with the prompt payment provisions of California Insurance Code §10123.13(a) or California Insurance Code §10123.147(a) in order to indemnify the insured for payment of any fees that are the legal obligation of the Insurer 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 penalties by the CDI.