California Physician

State law requires Knox-Keene licensed health plans to acknowledge receipt of all claims, whether or not they are complete. If a plan—or its contracting medical groups or IPAs—repeatedly fails to do so, the state’s new unfair payment practices regulations authorize enforcement action by the Department of Managed Health Care (DMHC).

Health plans must acknowledge receipt of electronically submitted claims within two working days and paper claims within 15 working days. If an incomplete claim is received, health plans must acknowledge receipt of the claim so long as the claim identifies the provider. If the claim is missing necessary payment information, the plan may simultaneously acknowledge receipt of the claim and deny the claim as incomplete.

Physicians are encouraged to keep a record of all claim submission dates and to save claim-receipt acknowledgements they receive back from health plans. Physicians will then be able to provide DMHC with the evidence the department needs to take action against violators of the new regulations. Provider complaint forms are available in the Unfair Payment Practices Resource Center.

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.

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 are also available online.

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.

Previous Payor Abuse Rules:

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.