Current through Register 2024 Notice Reg. No. 12, March 22, 2024
All health care service plans and their capitated providers
that pay claims (plan's capitated provider) shall establish a fast, fair and
cost-effective dispute resolution mechanism to process and resolve contracted
and non-contracted provider disputes. The plan and the plan's capitated
provider may maintain separate dispute resolution mechanisms for contracted and
non-contracted provider disputes and separate dispute resolution mechanisms for
claims and other types of billing and contract disputes, provided that each
mechanism complies with sections
1367(h),
1371,
1371.1,
1371.2,
1371.22,
1371.35,
1371.36,
1371.37,
1371.4,
and
1371.8
of the Health and Safety Code and sections
1300.71,
1300.71.38,
1300.71.4, and
1300.77.4 of title 28. Arbitration
shall not be deemed a provider dispute or a provider dispute resolution
mechanism for the purposes of this section.
(a) Definitions:
(1) "Contracted Provider Dispute" means a
contracted provider's written notice to the plan or the plan's capitated
provider challenging, appealing or requesting reconsideration of a claim (or a
bundled group of substantially similar multiple claims that are individually
numbered) that has been denied, adjusted or contested or seeking resolution of
a billing determination or other contract dispute (or a bundled group of
substantially similar multiple billing or other contractual disputes that are
individually numbered) or disputing a request for reimbursement of an
overpayment of a claim that contains, at a minimum, the following information:
the provider's name; the provider's identification number; contact information;
and:
(A) If the dispute concerns a claim or a
request for reimbursement of an overpayment of a claim, a clear identification
of the disputed item, the date of service and a clear explanation of the basis
upon which the provider believes the payment amount, request for additional
information, request for reimbursement for the overpayment of a claim, contest,
denial, adjustment or other action is incorrect;
(B) If the dispute is not about a claim, a
clear explanation of the issue and the provider's position thereon;
and
(C) If the dispute involves an
enrollee or group of enrollees: the name and identification number(s) of the
enrollee or enrollees, a clear explanation of the disputed item, including the
date of service and the provider's position thereon.
(2) "Non-Contracted Provider Dispute" means a
non-contracted provider's written notice to the plan or the plan's capitated
provider challenging, appealing or requesting reconsideration of a claim (or a
bundled group of substantially similar claims that are individually numbered)
that has been denied, adjusted or contested or disputing a request for
reimbursement of an overpayment of a claim that contains, at a minimum, the
following information: the provider's name, the provider's identification
number, contact information and:
(A) If the
dispute concerns a claim or a request for reimbursement of an overpayment of a
claim, a clear identification of the disputed item, including the date of
service, and a clear explanation of the basis upon which the provider believes
the payment amount, request for additional information, contest, denial,
request for reimbursement of an overpayment of a claim or other action is
incorrect.
(B) If the dispute
involves an enrollee or group of enrollees, the name and identification
number(s) of the enrollee or enrollees, a clear explanation of the disputed
item, including the date of service and the provider's position
thereon.
(3) "Date of
receipt" means the working day when the provider dispute or amended provider
dispute, by physical or electronic means, is first delivered to the plan's or
the plan's capitated provider's designated dispute resolution office or post
office box. This definition shall not affect the presumption of receipt of mail
set forth in Evidence Code section
641.
(4) "Date of Determination" means the date of
postmark or electronic mark on the written provider dispute determination or
amended provider dispute determination that is delivered, by physical or
electronic means, to the claimant's office or other address of record. To the
extent that a postmark or electronic mark is unavailable to confirm the Date of
Determination, the Department may consider, when auditing the plan's or the
plan's capitated provider's provider dispute mechanism, the date the check is
printed for any monies determined to be due and owing the provider and date the
check is presented for payment. This definition shall not affect the
presumption of receipt of mail set forth in Evidence Code section
641.
(5) "Plan" for the purposes of this section
means a licensed health care service plan and its contracted claims processing
organization(s).
(b)
Notice to Provider of Dispute Resolution Mechanism(s). Whenever the plan or the
plan's capitated provider contests, adjusts or denies a claim, it shall inform
the provider of the availability of the provider dispute resolution mechanism
and the procedures for obtaining forms and instructions, including the mailing
address, for filing a provider dispute.
(c) Submission of Provider Disputes. The plan
and the plan's capitated provider shall establish written procedures for the
submission, receipt, processing and resolution of contracted and non-contracted
provider disputes that, at a minimum, provide that:
(1) Provider disputes be submitted utilizing
the same number assigned to the original claim; thereafter the plan or the
plan's capitated provider shall process and track the provider dispute in a
manner that allows the plan, the plan's capitated provider, the provider and
the Department to link the provider dispute with the number assigned to the
original claim.
(2) Contracted
Provider Disputes be submitted in a manner consistent with procedures disclosed
in sections
1300.71 (l)(1)
-(4).
(3) Non-contracted Provider
Disputes be submitted in a manner consistent with the directions for obtaining
forms and instructions for filing a provider dispute attached to the plan's or
the plan's capitated provider's notice that the subject claim has been denied,
adjusted or contested or pursuant to the directions for filing Non-contracted
Provider Disputes contained on the plan's or the plan's capitated provider's
website.
(4) The plan shall resolve
any provider dispute submitted on behalf of an enrollee or a group of enrollees
treated by the provider in the plan's consumer grievance process and not in the
plan's or the plan's capitated provider's dispute resolution mechanism. The
plan may verify the enrollee's authorization to proceed with the grievance
prior to submitting the complaint to the plan's consumer grievance process.
When a provider submits a dispute on behalf of an enrollee or a group of
enrollees, the provider shall be deemed to be joining with or assisting the
enrollee within the meaning of section
1368
of the Health and Safety Code.
(d) Time Period for Submission.
(1) Neither the plan nor the plan's capitated
provider that pays claims, except as required by any state or federal law or
regulation, shall impose a deadline for the receipt of a provider dispute for
an individual claim, billing dispute or other contractual dispute that is less
than 365 days of plan's or the plan's capitated provider's action or, in the
case of inaction, that is less than 365 days after the Time for Contesting or
Denying Claims has expired. If the dispute relates to a demonstrable and unfair
payment pattern by the plan or the plan's capitated provider, neither the plan
nor the plan's capitated provider shall impose a deadline for the receipt of a
dispute that is less than 365 days from the plan's or the plan's capitated
provider's most recent action or in the case of inaction that is less than 365
days after the most recent Time for Contesting or Denying Claims has
expired.
(2) The plan or the plan's
capitated provider may return any provider dispute lacking the information
enumerated in either section (a)(1) or (a)(2), if the information is in the
possession of the provider and is not readily accessible to the plan or the
plan's capitated provider. Along with any returned provider dispute, the plan
or the plan's capitated provider shall clearly identify in writing the missing
information necessary to resolve the dispute consistent with sections
1300.71(a)(10) and
(11) and
1300.71(d)(1), (2) and
(3). Except in situation where the claim
documentation has been returned to the provider, no plan or a plan's capitated
provider shall request the provider to resubmit claim information or supporting
documentation that the provider previously submitted to the plan or the plan's
capitated provider as part of the claims adjudication process.
(3) A provider may submit an amended provider
dispute within thirty (30) working days of the date of receipt of a returned
provider dispute setting forth the missing information.
(e) Time Period for Acknowledgment. A plan or
a plan's capitated provider shall enter into its dispute resolution mechanism
system(s) each provider dispute submission (whether or not complete), and shall
identify and acknowledge the receipt of each provider dispute:
(1) In the case of an electronic provider
dispute, the acknowledgement shall be provided within two (2) working days of
the date of receipt of the electronic provider dispute by the office designated
to receive provider disputes, or
(2) In the case of a paper provider dispute,
the acknowledgement shall be provided within fifteen (15) working days of the
date of receipt of the paper provider dispute by the office designated to
receive provider disputes.
(f) Time Period for Resolution and Written
Determination. The plan or the plan's capitated provider shall resolve each
provider dispute or amended provider dispute, consistent with applicable state
and federal law and the provisions of sections
1371,
1371.1,
1371.2,
1371.22,
1371.35,
1371.37,
1371.4
and
1371.8
of the Health and Safety Code and section
1300.71,
1300.71.38,
1300.71.4 and
1300.77.4 of title 28, and issue a
written determination stating the pertinent facts and explaining the reasons
for its determination within 45 working days after the date of receipt of the
provider dispute or the amended provider dispute.
Copies of provider disputes and determinations, including
all notes, documents and other information upon which the plan or the plan's
capitated provider relied to reach its decision, and all reports and related
information shall be retained for at least the period specified in section
1300.85.1 of title
28.
(g) Past Due Payments.
If the provider dispute or amended provider dispute involves a claim and is
determined in whole or in part in favor of the provider, the plan or the plan's
capitated provider shall pay any outstanding monies determined to be due, and
all interest and penalties required under sections
1371
and
1371.35
of the Health and Safety Code and section
1300.71 of title 28, within five
(5) working days of the issuance of the Written Determination. Accrual of
interest and penalties for the payment of these resolved provider disputes
shall commence on the day following the expiration of "Time for Reimbursement"
as forth in section
1300.71(g).
(h) Designation of Plan Officer. The plan and
the plan's capitated provider shall each designate a principal officer, as
defined by section
1300.45(o) of
title 28, to be primarily responsible for the maintenance of their respective
provider dispute resolution mechanism(s), for the review of its operations and
for noting any emerging patterns of provider disputes to improve administrative
capacity, plan-provider relations, claim payment procedures and patient care.
The designated principal officer shall be responsible for preparing, the
reports and disclosures as specified in sections
1300.71(e)(3) and
(q) and
1300.71.38(k) of
title 28.
(i) No Discrimination.
The plan or the plan's capitated provider shall not discriminate or retaliate
against a provider (including but not limited to the cancellation of the
provider's contract) because the provider filed a contracted provider dispute
or a non-contracted provider dispute.
(j) Dispute Resolution Costs. A provider
dispute received under this section shall be received, handled and resolved by
the plan and the plan's capitated provider without charge to the provider.
Notwithstanding the foregoing, the plan and the plan's capitated provider shall
have no obligation to reimburse a provider for any costs incurred in connection
with utilizing the provider dispute resolution mechanism.
(k) Required Reports. Beginning with the 2004
calendar year and for each subsequent year, the plan shall submit to the
Department no more than fifteen (15) days after the close of the calendar year,
an "Annual Plan Claims Payment and Dispute Resolution Mechanism Report,"
described in part in Section
1300.71(q) of
this regulation, on an electronic form to be supplied by the Department Managed
Health Care pursuant to section
1300.41.8 of title 28 containing
the following, which shall be reported based upon the date of receipt of the
provider dispute or amended provider dispute:
(1) Information on the number and types of
providers using the dispute resolution mechanism;
(2) A summary of the disposition of all
provider disputes, which shall include an informative description of the types,
terms and resolution. Disputes contained in a bundled submission shall be
reported separately as individual disputes. Information may be submitted in an
aggregate format so long as all data entries are appropriately footnoted to
provide full and fair disclosure; and
(3) A detailed, informative statement
disclosing any emerging or established patterns of provider disputes and how
that information has been used to improve the plan's administrative capacity,
plan-provider relations, claim payment procedures, quality assurance system
(process) and quality of patient care (results) and how the information has
been used in the development of appropriate corrective action plans. The
information provided pursuant to this paragraph shall be submitted with, but
separately from the other portions of the Annual Plan Claims Payment and
Dispute Resolution Mechanism Report and may be accompanied by a cover letter
requesting confidential treatment pursuant section
1007 of title 28.
(4) The first report shall be due on or
before January 15, 2005.
(l) Confidentiality.
(1) The plan's Annual Plan Claims Payment and
Dispute Resolution Mechanism Report to the Department regarding its dispute
resolution mechanism shall be public information except for information
disclosed pursuant to section (k)(3) above, that the Director, pursuant to a
plan's written request, determines should be maintained on a confidential
basis.
(2) The plan's quarterly
disclosures pursuant to section
1300.71(q)(1)
shall be public information except for the information relating to the plan's
corrective action strategies that the Director, pursuant to a plan's written
request, determines should be maintained on a confidential
basis.
(m) Review and
Enforcement.
(1) The Department shall review
the plan's and the plan's capitated provider's provider dispute resolution
mechanism(s), including the records of provider disputes filed with the plan
and remedial action taken pursuant to section
1300.71.38(m)(3),
through medical surveys and financial examinations under sections
1380,
1381
or
1382
of the Health and Safety Code, and when appropriate, through the investigation
of complaints of unfair provider dispute resolution mechanism(s).
(2) The failure of a plan to comply with the
requirements of this regulation shall be a basis for disciplinary action
against the plan. The civil, criminal, and administrative remedies available to
the Director under the Health and Safety Code and this regulation are not
exclusive, and may be sought and employed in any combination deemed advisable
by the Director to enforce the provisions of this regulation.
(3) Violations of the Act and this regulation
are subject to enforcement action whether or not remediated, although a plan's
self-identification and self-initiated remediation of violations or
deficiencies may be considered in determining the appropriate
penalty.
1. New
section filed 7-24-2003; operative 8-23-2003 (Register 2003, No.
30).
Note: Authority cited: Sections
1344
and
1371.38,
Health and Safety Code. Reference: Sections
1367,
1371
and
1371.38,
Health and Safety Code.