28 CA ADC § 1300.75.4.7


      28 CCR s 1300.75.4.7

      Cal. Admin. Code tit. 28, s 1300.75.4.7


      CALIFORNIA CODE OF REGULATIONS
      TITLE 28. MANAGED HEALTH CARE
      DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
      CHAPTER 2. HEALTH CARE SERVICE PLANS
      ARTICLE 9. FINANCIAL RESPONSIBILITY
      RISK-BEARING ORGANIZATIONS
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.75.4.7. Organization Evaluation.

      (a) Every contract involving a risk arrangement between a plan and an 
      organization shall:

      (1) Require the organization to comply with the Department of Managed 
      Health Care's review and audit process, in determining the organization's 
      satisfaction of the Grading Criteria; and

      (2) Permit the Department to perform any of the following activities in 
      conjunction with the plan's oversight process:

      (A) Obtain and evaluate supplemental financial information pertaining to 
      the organization when: 1. the organization fails to satisfactorily 
      demonstrate its compliance with the Grading Criteria; 2. the organization 
      experiences an event that materially alters its ability to remain 
      compliant with the Grading Criteria; 3. the external party's review or 
      audit process indicates that the organization may have insufficient 
      financial capacity to continue to accept financial risk for the delivery 
      of health care services consistent with the requirements of sections 
      1300.70(b)(2)(H)(1) of Title 28, California Code of Regulations; or 4. the 
      Department receives information from complaints submitted to the HMO Help 
      Center, health plan reporting, medical audits and surveys or any other 
      source that indicates the organization may be delaying referrals or 
      authorizations or failing to meet access standards for basic health care 
      services based on financial considerations.


      


      Note: Authority cited: Sections 1344 and 1375.4, Health and Safety Code. 
      Reference: Section 1375.4, Health and Safety Code. 

       HISTORY 
         
      1. New section filed 8-10-2005; operative 9-9-2005 (Register 2005, No. 
32).
      28 CA ADC s 1300.75.4.7

      END OF DOCUMENT

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