SILENT PPO (NON-EXISTENT CONTRACT)
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
A health plan is required to identify, in its explanation of benefits, the name of the plan or network in which that plan has attempted to access in order to apply discounted rates on the reimbursement of claims.
TIMEFRAMES FOR POSTSTABILIZATION DENIALS OR AUTHORIZATIONS
Last Updated: November 20, 2021 | Jurisdictions: AL HMO CA HMO CO HMO FL HMO IN HMOs KS HMO MA MO HMO NJ HMO NY HMO OH HMO PA HMO RI HMO TX HMO VHA
MA organization required to respond within (1) hour if services are not pre-approved.
UNAUTHORIZED TREATMENT
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
Physicians who make isolated mistakes, such as failing to obtain prior written authorization, are entitled to reimbursement, as long as they have made a good-faith effort to comply with the plan's rules.
UNCONTESTED PORTION OF CLAIM DENIAL
Last Updated: March 30, 2021 | Jurisdictions: CA HMO
A health plan is required to reimburse any uncontested portion of a claim (e.g. emergency services) within 30 working days from the date of receipt. Health Maintenance Organizations (HMOs) are required to reimburse any uncontested portion of claim within 45 working days from the date of receipt. A plan's repeated failure to reimburse uncontested portions of claims within these timeframes constitutes an "unfair payment pattern."
UNDERPAYMENT – CONTRACTED PROVIDERS
Last Updated: November 19, 2021 | Jurisdictions: CA HMO MA
The MA organization is obligated to pay contracted providers under the terms of the contract between the MA organization and the provider. (Emphasis added.)
UNDERPAYMENT – NON-CONTRACTED PROVIDERS
Last Updated: November 19, 2021 | Jurisdictions: CA HMO MA
Any provider (other than a provider of services in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.
UNTIMELY FILING
Last Updated: November 22, 2021 | Jurisdictions: CA HMO CA PPO MA
The claim must be filed no later than the close of the period ending (1) calendar year after the date of service.
UNTIMELY FILING – EXCEPTIONAL CIRCUMSTANCE
Last Updated: November 30, 2021 | Jurisdictions: CA HMO
An insurer may not refuse to process a claim due solely to lack of timely filing unless the insurer can prove that it was substantially prejudiced by the late filing and where there is no question of the medical necessity of medical care by a physician, and there is no suggestion of fraud, gross negligence or willful misconduct, insurers cannot enforce a submission requirements.