28 CA ADC § 1300.71.38
28 CCR s 1300.71.38
Cal. Admin. Code tit. 28, s 1300.71.38
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 8. SELF-POLICING PROCEDURES
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.71.38. Fast, Fair and Cost-Effective Dispute Resolution Mechanism.
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.
Note: Authority cited: Sections 1344 and 1371.38, Health and Safety Code.
Reference: Sections 1367, 1371 and 1371.38, Health and Safety Code.
HISTORY
1. New section filed 7-24-2003; operative 8-23-2003 (Register 2003, No.
30).
28 CA ADC s 1300.71.38
END OF DOCUMENT
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