Cal. Code Regs. tit. 28 § 1300.77.4

Current through Register 2024 Notice Reg. No. 49, December 6, 2024

Section 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.

Cal. Code Regs. Tit. 28, § 1300.77.4

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 of Regulations (Register 2000, No. 29).

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