California Physician

California law prohibits Knox-Keene licensed health plans from imposing claim submission deadlines that are less than 90 days from the date of service for contracted physicians and 180 days for noncontracted physicians. Should a claim be filed after these deadlines, plans are still required to pay the claim if the physician submits a provider dispute form showing "good cause" for the delay.

Although the state’s new unfair payment practices regulations do not define "good cause," the California Department of Managed Health Care (DMHC) has said it will review and evaluate the criteria plans use in adjudicating late claim submissions, indicating it will be "the determiner of good cause." The regulations also authorize DMHC to penalize plans that impose unreasonable deadlines or engage in other unfair payment practices.

To minimize the risk of late claim denials, CMA encourages physicians to submit claims early and whenever possible to submit them electronically. Physicians should review any claims that are denied for late filing for compliance with these fair payment rules. It is important for physicians to report unfair health plan payment practices to DMHC, so that the department can act against plans that fail to comply with the new regulations.

Please contact CMA’s Center for Economic Services at 888/401-5911 before filing a complaint so that our reimbursement specialists can guide you through the complaint-submission process and advise you on the supporting documentation DMHC will require to substantiate an unfair payment practice complaint. Please also fax a copy of your complete complaint to CMA’s Center for Economic Services at 916/551-2027. This will allow CMA reimbursement specialists to monitor DMHC enforcement. Provider complaint forms are available in the Unfair Payment Practices Resource Center.

To further help physicians, CMA has developed the interactive “Payor Abuse Matters—React Now” CD-ROM. The CD is free to members ($100 for nonmembers). A printed version is available to members for $25 ($125 for nonmembers). To order, contact your local county medical society or call CMA’s publications line, 800/882-1262. Order forms can also be downloaded by clicking here.

For more information on unfair payment practices, see ON-CALL document #1051, “Physician Complaints/Unfair Payment Practices.” ON-CALL documents are free to members at CMA’s members-only website. Nonmembers can purchase ON-CALL documents for $2 per page at CMA’s online bookstore.

TO ORDER THE PAYOR ABUSE CD-ROM: Call your county medical society or CMA’s publications line, 800/882-1262.

TO REPORT AN UNFAIR PAYMENT PRACTICE or for help with other reimbursement related issues: Call CMA’s reimbursement help line, 888/401-5911, or e-mail awetzel@cmanet.org.