CA HMO Script – LA City Ambulance Transport No Contract Underpayment
Last Updated: November 19, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: Did this transport originate in the City of Los Angeles? Are we contracted with the plan? What date was the claim initially billed? When did the plan underpay the claim? Did they underpay the claim LATE, without the required statutory interest? How many days is the plan in violation of the above prompt... View more
CA HMO Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: Who denied the claim? What is the professional’s license number with the State Medical Board? Were they a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider per Health and Safety Code §1370.2? Did the... View more
CA HMO Script – Misdirected Claims
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Which entity was billed initially (the plan or capitated provider?) What date was the claim was initially billed? Did the entity who received the claim in error follow the rules listed below? Are the two entities still in disagreement over payment responsibility? If the capitated provider is financially responsible? How many days is... View more
CA HMO Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: What was the patient’s presenting symptoms or chief complaint in the emergency room? Did the plan pay for the medical screening, examination and evaluation necessary to determine if medical emergency exists? What criteria (final diagnosis code, etc.) did the plan rely upon to determine these services as “non-emergent?” The staff will be firm... View more
CA HMO Script – No Claim on File
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Was the claim billed electronically or physically? What date was the claim initially billed? Do we have a clearing house receipt confirming delivery? 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... View more
CA HMO Script – No Contract Underpayment
Last Updated: November 19, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: What date was the claim initially billed? When did the plan underpay the claim? Did they underpay the claim LATE, without the required statutory interest? How many days is the plan in violation of the above prompt pay statute? What type of underpayment is it (UCR, DRG, APC, etc.)? The staff will be... View more
CA HMO Script – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: What date was the request for non-urgent authorization made? Was there any written communication (request for information, denial, etc.) from the payor? If so, how long after the request was made did you receive any written communication? How many days is the plan in violation of the statutory authorization timeframe under Health and... View more
CA HMO Script – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: Who denied the claim? What is the professional’s license number with the State Medical Board? Were they a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider per Health and Safety Code §1367.01(h)(4)? Did the... View more
CA HMO Script – Patient not Eligible
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Was the coverage terminated? Did we verify eligibility? IF SO, WHAT DATE? Did the plan make negligent misrepresentation of the patient’s eligibility? Did we get an authorization or tracking number? IF SO, WHAT DATE? Did we treat pursuant to the plan’s verification and authorization in good faith? Is the plan refusing to comply... View more
CA HMO Script – Poststabilization Timeframe
Last Updated: November 20, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: When was the patient stabilized in the emergency room or admitted as an inpatient? Was it during normal business hours (M-F, etc?) Did the hospital make initial contact with the plan successfully? Who did they speak with? Was a reference, tracking, or authorization number given? IF SO, WHAT DATE? If not, did the... View more