MATERNITY COVERAGE (FREE DEMO)
Last Updated: October 22, 2021 | Jurisdictions: AL HMO CA HMO CA PPO CO HMO ERISA FL HMO GA HMO IN HMOs MA MO HMO NV HMO NJ HMO NY HMO PA HMO RI HMO TX HMO VHA
The payor has a duty to provide all Medicare-covered services and is mandated by federal law to cover these services.
TIMELY PAYMENT – DEFINITION OF A CLEAN CLAIM (FREE DEMO)
Last Updated: October 18, 2021 | Jurisdictions: AL HMO CA HMO CA PPO CO HMO ERISA FL HMO GA HMO IN HMOs KS HMO MA MI HMO MO HMO NV HMO NJ HMO NY HMO OH HMO PA HMO RI HMO TX HMO VHA
The MA organization must pay interest on clean claims that are not paid within 30 days in accordance with sections 1816(c)(2)(B) and 1842(c)(2)(B).
CONCURRENT DISAGREEMENT OF CARE – POST-STABILIZATION SERVICES
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
Upon entering a disagreement of care (e.g. level of care, services requested) with a treating provider, a health plan is required to assume responsibility of the patient by having a plan provider assume responsibility for the care of the patient or by having a plan hospital accept transfer of the patient.
COORDINATION OF BENEFITS DENIAL
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
A health plan's request for information necessary to determine payor liability (e.g. Medicare EOB) does not extend the plan's obligation to meet prompt reimbursement or denial of claim timeframes as defined under state law.
ETAR AUTHORIZATION TIMEFRAME
Last Updated: March 30, 2021 | Jurisdictions: Medi-Cal
Decisions regarding non-emergent prior authorizations shall be provided within five working days from the department's reciept.
INTEREST OWED ON LATE CLAIMS
Last Updated: October 22, 2021 | Jurisdictions: AL HMO CA HMO CA PPO CO HMO FL HMO GA HMO IN HMOs KS HMO MA MI HMO MO HMO NV HMO NJ HMO NY HMO PA HMO RI HMO TX HMO VHA
Must pay interest on clean claims that are not paid within 30 days.
LA CITY UNDERPAID NON-CONTRACTED AMBULANCE TRANSPORT
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
Noncontracted payors must reimburse all transports originated in the City of Los Angeles per the legal rates set forth by the Board of Transportation in LA City Ordinance (#185210).
MEDICAL NECESSITY – QUALIFIED REVIEWERS
Last Updated: October 22, 2021 | Jurisdictions: AL HMO CA HMO CA PPO CO HMO ERISA FL HMO IN HMOs MA MO HMO NV HMO NY HMO PA HMO RI HMO TX HMO VHA
A determination must be reviewed by a physician or other appropriate health care professional with sufficient medical and other expertise, including knowledge of Medicare coverage criteria, before the MA organization issues the organization determination decision.
MISDIRECTED CLAIM
Last Updated: March 30, 2021 | Jurisdictions: CA HMO MA
Pursuant to 42 CFR ยง422.504(i), regardless of the relationship a health plan may have with first tier, downstream, and related entities, the health plan is ultimately responsible for adhering to and fully complying with all terms and conditions of its contract with CMS.
NO AUTHORIZATION FOR ER SERVICES AND CARE
Last Updated: February 2, 2024 | Jurisdictions: CA HMO CA PPO CO HMO ERISA FL HMO GA HMO IN HMOs KS HMO MA MO HMO NV HMO NY HMO OH HMO PA HMO RI HMO TX HMO VHA
An MA organization is financially responsible for emergency and urgently needed services regardless of whether there is a prior authorization for services