NO CLAIM ON FILE
Last Updated: March 30, 2021 | Jurisdictions: CA HMO MA
The contract between CMS and the MA organization must provide that the MA organization will pay 95% of the “clean claims” within 30 days of receipt. You are reminded that this office is monitoring any possible Health Insurance Portability and Accountability Act (HIPAA) violations.
NON-EMERGENT DENIAL
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
A health plan cannot deny reimbursement, or require authorization, for emergency services and the determination as to whether the patient reasonably believed that an emergent medical condition existed cannot be based solely on a retrospective review of the discharge status or level of care eventually provided to the patient.
NON-URGENT AUTHORIZATION TIMEFRAMES
Last Updated: November 21, 2021 | Jurisdictions: AL HMO CA HMO CA PPO CO HMO ERISA IN HMOs KS HMO MA MO HMO NJ HMO NY HMO OH HMO PA HMO RI HMO TX HMO
"As the enrollee's health condition requires, but not later than 14 calendar days after the date of the organization receives the request for standard organization determination."
NOTICE REQUIREMENTS FOR ADVERSE DETERMINATIONS
Last Updated: October 18, 2021 | Jurisdictions: AL HMO CA HMO CA PPO CO HMO ERISA FL HMO IN HMOs KS HMO MA MI HMO MO HMO NV HMO NJ HMO NY HMO PA HMO RI HMO TX HMO VHA
Denial must include language in understandable form, state a specific reason, inform the enrollee of appeal rights, and comply with all other notice requirements by CMS.
OVERPAYMENT OFFSET
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
A health plan may only offset an overpayment of a claim against the provider's current claim submission when the provider fails to reimburse the overpayment within the specified timeframe and when the provider has entered into a written contract that specifically authorizes the plan to offset uncontested overpayments against current claim submissions.
PATIENT NOT ELIGIBLE
Last Updated: March 30, 2021 | Jurisdictions: CA HMO CA PPO
A health plan cannot rescind or modify an authorization for healthcare services after such services are rendered for any reason, including the plan's subsequent determination that it did not make an accurate determination of the enrollee's eligibility.
REFUND RECOUPMENTS
Last Updated: November 20, 2021 | Jurisdictions: AL HMO CA HMO CA PPO CO HMO FL HMO GA HMO IN HMOs KS HMO MA MO HMO NJ HMO NY HMO OH HMO PA HMO RI HMO TX HMO
"…if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of medical necessity."
REQUEST FOR INSIGNIFICANT INFORMATION
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
A health plan cannot delay payment on a claim by requesting information that is not reasonably relevant for a claims adjudicator with appropriate competence to timely and accurately determine the extent of the plan's financial liability.
RETROACTIVE DENIAL – TREND
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
A health plan cannot rescind or modify an authorization for healthcare services after such services are rendered for any reason, including the plan's subsequent determination that it did not make an accurate determination of the enrollee's eligibility. A health plan's attempt to rescind or modify authorizations on three or more occasions over a three-month period constitutes a "demonstrable and unjust payment pattern."
RETROACTIVE DENIALS FOR AUTHORIZED CARE
Last Updated: October 18, 2021 | Jurisdictions: CA HMO CA PPO CO HMO FL HMO GA HMO IN HMOs MA MO HMO NJ HMO NY HMO TX HMO VHA
"…if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of medical necessity."