CA HMO Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: How many days after payment, did the Knox-Keene plan request the refund? Why did the plan request the money back? Were services pre-approved and rendered in good faith? Were services statutorily authorized due to (plan’s) failure to approve or disapprove care within the required time frame? Is the recovery request lawful? Did the... View more
CA HMO Script – Request for Insignificant Information
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Was the claim billed electronically or physically? What date was the claim initially billed? Were the services authorized? Was the plan’s request for information reasonably relevant? Is the requested information in the possession of this facility? Has there been a repeated delay in the processing of this claim? The objective is to bring... View more
CA HMO Script – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | 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 a reference, tracking, or authorization number? IF SO, WHAT DATE? Did we treat pursuant to the plan’s verification and authorization in good faith? Is the plan refusing to... View more
CA HMO Script – Retroactive Denial Trend
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 negligently misrepresent 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 with Health... View more
CA HMO Script – Silent PPO
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Make sure we are not 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 prompt payment statute? What type of underpayment is it... View more
CA HMO Script – Unauthorized Treatment
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Who denied the claim (name, title)? 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?... View more
CA HMO Script – Uncontested Portion of Claim Denial
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
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... View more
CA HMO Script – Unlawful Offset
Last Updated: September 3, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: How many days after payment, did the Knox-Keene plan request the refund? Why did the plan request the money back? Were services pre-approved and rendered in good faith? Were services statutorily authorized due to (plan’s) failure to approve or disapprove care within the required time frame? Is the recovery request lawful? Did the... View more
CA HMO Script – Untimely Filing
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Is this claim or appeal “truly” filed late or has the plan mishandled the initial timely submission of the claim/appeal? (If the claim is “truly” filed late, proceed to next bullet point, if not see NO CLAIM ON FILE policy.) When was the patient discharged? What date was the claim billed and to... View more
CA HMO Script – Untimely Filing Medical Necessity Exception
Last Updated: September 3, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Is this claim or appeal “truly” filed late or has the plan mishandled the initial timely submission of the claim/appeal? (If the claim is “truly” filed late, proceed to next bullet point, if not see NO CLAIM ON FILE policy.) When was the patient discharged? What date was the claim billed and to... View more