Bill Text: CA AB3275 | 2023-2024 | Regular Session | Amended
Bill Title: Health care coverage: claim reimbursement.
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Enrolled) 2024-08-29 - Senate amendments concurred in. To Engrossing and Enrolling. (Ayes 74. Noes 0.). [AB3275 Detail]
Download: California-2023-AB3275-Amended.html
Amended
IN
Senate
August 23, 2024 |
Amended
IN
Senate
June 27, 2024 |
Amended
IN
Assembly
May 16, 2024 |
Amended
IN
Assembly
April 18, 2024 |
Amended
IN
Assembly
April 01, 2024 |
Introduced by Assembly Members Soria and Robert Rivas (Coauthor: Assembly Member Aguiar-Curry) |
February 16, 2024 |
LEGISLATIVE COUNSEL'S DIGEST
Existing law creates the Managed Care Administrative Fines and Penalties Fund.
This bill would require that an administrative fee assessed upon a health care service plan for a violation of the above-describe provisions related to clean claim reimbursement be deposited into the fund. The bill would require those moneys to be retained in the fund to assist enrollees and providers impacted by a violation, upon appropriation by the Legislature.
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YESBill Text
The people of the State of California do enact as follows:
For purposes of Sections 1371 and 1371.35, as added by the act that added this section, the department, in consultation with the Department of Health Care Services and informed by a stakeholder process, shall determine the criteria for a clean claim no later than July 31, 2025. To the extent permitted under federal law, the department shall not rely on federal standards for purposes of this section.
SEC. 2.SECTION 1.
Section 1371 of the Health and Safety Code is amended to read:1371.
(a) (1) A health care service plan, including a specialized health care service plan, shall reimburse claims or a portion of a claim, whether in state or out of state, as soon as practicable, but no later than 30 working days after receipt of the claim by the health care service plan, or if the health care service plan is a health maintenance organization, 45 working days after receipt of the claim by the health care service plan, unless the claim or portion thereof is contested by the plan, in which case the claimant shall be notified, in writing, that the claim is contested or denied, within 30 working days after receipt of the claim by the health care service plan, or if the health care service plan is a health maintenance organization, 45 working days after receipt of the claim by the health care service plan. The notice that a claim is being contested shall identify the portion of the claim that is contested and the specific reasons for contesting the claim.SEC. 3.SEC. 2.
Section 1371 is added to the Health and Safety Code, to read:1371.
(a) (1) A health care service plan, including a specialized health care service plan, shall reimburse a(d)This section applies to Medi-Cal managed care plan contracts entered into with the State Department of Health Care Services pursuant to Chapter 7 (commencing Section 14000) or Chapter 8 (commending with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
(e)
(f)
(a)Notwithstanding subdivision (c) of Section 1341.45, an administrative penalty assessed upon a plan for violation of Section 1371 or 1371.35 shall be deposited in the Managed Care Administrative Fines and Penalties Fund and shall be retained in the fund to assist enrollees and providers impacted by violations of Section 1371 or 1371.35, upon appropriation by the Legislature.
(b)This section shall become operative on January 1, 2026.
SEC. 5.SEC. 3.
Section 1371.34 is added to the Health and Safety Code, to read:1371.34.
(a) A complaintSEC. 6.SEC. 4.
Section 1371.35 of the Health and Safety Code is amended to read:1371.35.
(a) A health care service plan, including a specialized health care service plan, shall reimburse each complete claim, or portion thereof, whether in state or out of state, as soon as practical, but no later than 30 working days after receipt of the complete claim by the health care service plan, or if the health care service plan is a health maintenance organization, 45 working days after receipt of the complete claim by the health care service plan. However, a plan may contest or deny a claim, or portion thereof, by notifying the claimant, in writing, that the claim is contested or denied, within 30 working days after receipt of the claim by the health care service plan, or if the health care service plan is a health maintenance organization, 45 working days after receipt of the claim by the health care service plan. The notice that a claim, or portion thereof, is contested shall identify the portion of the claim that is contested, by revenue code, and the specific information needed from the provider to reconsider the claim. The notice that a claim, or portion thereof, is denied shall identify the portion of the claim that is denied, by revenue code, and the specific reasons for the denial. A plan may delay payment of an uncontested portion of a complete claim for reconsideration of a contested portion of that claim so long as the plan pays those charges specified in subdivision (b).SEC. 7.SEC. 5.
Section 1371.35 is added to the Health and Safety Code, to read:1371.35.
(a) (1) A health care service plan, including a specialized health care service plan, shall reimburse a(m)This section applies to Medi-Cal managed care plan contracts entered into with the State Department of Health Care Services pursuant to Chapter 7 (commencing Section 14000) or Chapter 8 (commending with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
(n)
(o)
SEC. 8.SEC. 6.
Section 10123.13 of the Insurance Code is amended to read:10123.13.
(a) Every insurer issuing group or individual policies of health insurance thatSEC. 9.SEC. 7.
Section 10123.13 is added to the Insurance Code, to read:10123.13.
(a)(2)The notice that a claim or portion thereof is contested shall identify the portion of the claim that is contested, by revenue code, and the specific information needed from the provider to reconsider the claim including any defect or impropriety, or additional information needed to adjudicate the claim.
(3)The notice that a claim or portion thereof, is denied shall identify the portion of the claim that is denied, by revenue code, and the specific reasons for the denial, including any defect or impropriety or additional information needed to adjudicate the claim.
(4)The insurer shall provide a copy of the notice to each insured who received services pursuant to the claim that was contested or denied and to the insured’s health care provider that provided the services at issue. The notice shall advise the provider who submitted the claim on behalf of the insured or pursuant to a contract for alternative rates of payment and the insured that either may seek review by the department of a claim that the insurer contested or denied, and the notice shall include the address, internet website address, and telephone number of the unit within the department that performs this review function. The notice to the provider may be included on either the explanation of benefits or remittance advice and shall also contain a statement advising the provider of its right to enter into the dispute resolution process described in Section 10123.137. The notice to the insured may also be included on the explanation of benefits.
(2)An insurer shall automatically include in its payment of the claim all interest that has accrued pursuant to this section without requiring the claimant to submit a request for the interest amount. An insurer failing to comply with this requirement shall pay the claimant a fee of the greater of fifteen dollars ($15) or 10 percent of the accrued interest.
SEC. 10.SEC. 8.
Section 10123.147 of the Insurance Code is amended to read:10123.147.
(a) Every insurer issuing group or individual policies of health insurance thatSEC. 11.SEC. 9.
Section 10123.147 is added to the Insurance Code, to read:10123.147.
(a)(2)The notice that a claim or portion thereof, is contested shall identify the portion of the claim that is contested, by revenue code, and the specific information needed from the provider to reconsider the claim, including any defect or impropriety or additional information needed to adjudicate the claim.
(3)The notice that a claim or portion thereof, is denied shall identify the portion of the claim that is denied, by revenue code, and the specific reasons for the denial, including any defect or impropriety or additional information needed to adjudicate the claim.
(4)The notice shall include the specific information needed from the provider to reconsider the claim, including any defect or impropriety or additional information needed to adjudicate the claim. The insurer shall provide a copy of the notice required by this subdivision to each insured who received services pursuant to the claim that was contested or denied and to the insured’s health care provider that provided the services at issue. The notice required by this subdivision shall include a statement advising the provider who submitted the claim on behalf of the insured or pursuant to a contract for alternative rates of payment and the insured that either may seek review by the department of a claim that was contested or denied by the insurer and the address, internet website address, and telephone number of the unit within the department that performs this review function. The notice to the provider may be included on either the explanation of benefits or remittance advice and shall also contain a statement advising the provider of its right to enter into the dispute resolution process described in Section 10123.137.
For purposes of Sections 10123.13 and 10123.147, as added by the act that added this section, the department, informed by a stakeholder process, shall determine the criteria for a clean claim no later than July 31, 2025. To the extent permitted under federal law, the department shall not rely on federal standards for the purposes of this section.