California Physician

Payor Abuse Resource Center
An Unfair Payment Practices Action Guide for Physicians

Rule #1: Fee Schedule Disclosure
Did you know that the State of California's new unfair payment practices regulations require all Knox-Keene licensed health plans to fully and regularly disclose to contracting physicians their fee schedules and payment rules, including instructions for submitting claims and filing provider disputes?

Rule #2: Advance Notice of Contract Changes
The State of California’s new unfair payment practices regulations require all Knox-Keene licensed health plans and their contracting medical groups/IPAs to notify contracted physicians in writing 45 days before instituting any changes to fee schedules and payment rules.

Rule #3: Preauthorization
Did you know that California law prohibits a health plan from preauthorizing treatment of a plan enrollee and then rescinding or modifying that authorization after the physician provides the service?

Rule #4: Claim Submission Deadlines
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.

Rule #5: Overpayment Notices
California's unfair payment practices law requires Knox-Keene licensed health plans to request refunds on overpaid claims to physicians in writing within one year of the original payment dates.

Rule #6: Acknowledgement of Claim Receipt
State law requires Knox-Keene licensed health plans to acknowledge receipt of all claims, whether or not they are complete.

Rule #7: Explanation of Claim Denial
When a Knox-Keene licensed health plan denies, adjusts, or contests a physician claim, the plan must provide the physician with a detailed written explanation of why the action was taken.

Rule #8: Notification of Dispute Resolution Mechanism
California’s unfair payment practices regulations require that Knox-Keene licensed health plan and their contracting medical groups/IPAs maintain fair, fast, and cost-effective payment dispute mechanisms for contracting and noncontracting physicians.

Rule #9: Health Plans Must Allow One Year to File Dispute
Did you know that the State of California’s new unfair payment practices regulations prohibit Knox-Keene licensed health plans and their contracting medical groups/IPAs from imposing provider dispute filing deadlines that are less than 365 days from the date of the plan’s disputed action?

Rule #10: Plans Must Resolve Disputes Within 45 Days
California’s new unfair payment practices regulations require Knox-Keene licensed health plans and their contracting medical groups/IPAs to resolve physician disputes in writing no more than 45 working days after receiving a physician dispute.

Rule #12: Plans Must Pay Interest on Late Payments
Knox-Keene licensed health plans are required to automatically pay interest and penalties when an uncontested physician claim is not paid within the allowed time frame (30 business days for PPOs, 45 for HMOs).