28 CA ADC § 1300.77.4


      28 CCR s 1300.77.4

      Cal. Admin. Code tit. 28, s 1300.77.4


      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 1300.77.4. Reimbursements on a Fee-for-Services Basis: Determination of 
      Status of Claims.

      Every plan shall institute procedures whereby all claim forms received by 
      the plan from providers of health care services for reimbursement on a 
      fee-for-service basis and from subscribers and enrollees for reimbursement 
      are maintained and accounted for in a manner which permits the 
      determination of the date of receipt of any claim, the status of any 
      claim, the dollar amount of unpaid claims at any time, and rapid retrieval 
      of any claim. Although any categories for status-determination held 
      unobjectionable by the Director may be used, for the purposes of this 
      section, the following status-determination categories, as a group, shall 
      be presumptively reasonable:

      (1) to be processed,

      (2) processed, waiting for payment,

      (3) pending, waiting for approval for payment or denial,

      (4) pending, waiting for additional information,

      (5) denied,

      (6) paid, and, if appropriate,

      (7) other. These procedures shall involve the use of either a claims log, 
      claims numbering system, electronic data processing records, and/or any 
      other method held unobjectionable by the Director.


      


      Note: Authority cited: Section 1344, Health and Safety Code. Reference: 
      Sections 1375.1, 1376 and 1377, Health and Safety Code. 


       HISTORY 
         
      1. New section filed 3-3-83; effective thirtieth day thereafter (Register 
      83, 
      No. 10).

      2. Change without regulatory effect amending first paragraph and 
      subsection (7)
      filed 7-18-2000 pursuant to 
      section 100, title 1, California Code ofRegulations (Register 2000, No. 
      29).
      28 CA ADC s 1300.77.4

      END OF DOCUMENT

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