Health Plan Amendment CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM This Claims Settlement Practices and Dispute Resolution

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Health Plan Amendment CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM This Claims Settlement Practices and Dispute Resolution Powered By Docstoc
					                      Health Plan Amendment
      CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION
                          MECHANISM


This Claims Settlement Practices and Dispute Resolution Mechanism Amendment
(“Amendment”) effective January 1, 2004 is made a part of the [Insert Agreement
Name] (“Agreement”) dated [Insert Date of Agreement] by and between [Insert Health
Plan Name] (“Plan”) and [insert Claims Processing Organization or IPA/Medical
Group Name] (“Capitated Provider”).

                                      RECITALS

A. WHEREAS, Plan and Capitated Provider are parties to the Agreement pursuant to
   which Capitated Provider has been delegated on behalf of Plan, to accept and
   adjudicate claims for specific health care services provided to Plan enrollees in
   accordance with the provisions of Sections 1371, 1371.1, 1371.2, 1371.22, 1371.35,
   1371.36, 1371.37, 1371.38, 1371.4 and 1371.8 of the California Health & Safety
   Code, and Title 28 of the California Code of Regulations Sections 1300.71.4, and
   1300.77.4.

B. WHEREAS, Sections 1300.71 and 1300.71.38 of Title 28 of the California Code of
   Regulations, Claims Settlement Practices and Dispute Resolution Mechanism
   Regulations, (“Claims and Dispute Regulations”) require that the Agreement be
   amended to include certain provisions to include certain specific provisions related to
   claims payment and dispute resolution.

C. WHEREAS, the purpose of this amendment is to satisfy the requirements of the
   Claims and Disputes Regulations.

NOW THEREFORE, in consideration of the mutual promises and covenants contained
herein, the parties agree as follows:

1. Definitions.
   Unless otherwise provided in this Amendment, capitalized terms have the same
   meaning as set forth in the Claims and Disputes Regulations.

2. Claim Adjudication
   Capitated Provider shall accept and adjudicate claims for health care services
   provided to Plan enrollees in accordance with the provisions of Sections 1371,
   1371.1, 1371.2, 1371.22, 1371.35, 1371.36, 1371.37, 1371.38, 1371.4 and 1371.8 of
   the California Health & Safety Code, and Sections 1300.71, 1300.71.38, 1300.71.4,
   and 1300.77.4 of Title 28 of the California Code of Regulations.



a501c35d-0cbd-4adf-89c2-0540c4e341e7.doc                                            1 of 3
ICE Approved 9-19-03                                                                         T-2
3. Balance Billing [OPTIONAL, if not otherwise addressed in Agreement.]
   Capitated Provider shall not invoice or balance bill a Plan’s enrollee for the difference
   between the Capitated Provider’s billed charges and the reimbursement paid by Plan
   for any covered benefit.

4. Dispute Resolution
   Capitated Provider shall establish and maintain a fair, fast and cost-effective dispute
   resolution mechanism to process and resolve provider disputes in accordance with the
   provisions of Sections 1371, 1371.1, 1371.2, 1371.22, 1371.35, 1371.36, 1371.37,
   1371.38, 1371. 4 and 1371.8 of the California Health & Safety Code, and Sections
   1300.71, 1300.71.38, 1300.71.4, and 1300.77.4 of Title 28 of the California Code of
   Regulations.

5. Reporting Requirements
   A. Capitated Provider shall submit a Quarterly Claims Payment Performance Report
      (“Quarterly Claims Report”) to Plan within thirty (30) calendar days of the close
      of each calendar quarter. The Quarterly Claims Report shall, at a minimum,
      disclose Capitated Provider’s compliance status with Sections 1371, 1371.1,
      1371.2, 1371.22, 1371.35, 1371.36, 1371.37, 1371.4 and 1371.8 of the California
      Health and Safety Code and Sections 1300.71, 1300.71.38, 1300.71.4 and
      1300.77.4 of Title 28 of the California Code of Regulations. In the event that the
      California Department of Managed Health Care promulgates a required report
      format for the Quarterly Claims Report, Capitated Provider shall submit its
      Quarterly Claims Report in this format. The first period of measurement shall be
      January 1, 2004 through March 31, 2004, which Quarterly Claims Report shall be
      submitted to the Plan by the Capitated Provider no later than April 30, 2004.

       (1) Capitated Provider shall ensure that each Quarterly Claims Report be signed
           by and include the written verification of a principal officer, as defined by
           Section 1300.45(o) of Title 28 of the California Code of Regulations, of
           Capitated Provider, stating that the report is true and correct to the best
           knowledge and belief of the principal officer.

       (2) Capitated Provider’s Quarterly Claims Report shall include a tabulated record
           of each provider dispute it received, categorized by date of receipt, and
           including the identification of the provider, type of dispute, disposition and
           working days to resolution, as to each provider dispute received. Each
           individual dispute contained in a provider’s bundled notice of provider dispute
           shall be reported separately to Plan.

   B. Capitated Provider shall make available to Plan and the California Department of
      Managed Health Care, all records, notes and documents regarding its provider
      dispute resolution mechanism and the resolution of its provider disputes.




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ICE Approved 9-19-03                                                                           T-2
6. Provider Right of Appeal for De Novo Review
   Any provider that submits a claim dispute to Capitated Provider’s dispute resolution
   mechanism involving an issue of medical necessity or utilization review shall have an
   unconditional right of appeal for that claim dispute to the Plan’s dispute resolution
   process for a de novo review and resolution for a period of sixty (60) working days
   from Capitated Provider’s Date of Determination.

7. Right to Assume Responsibility for Claims Processing
   Plan is authorized to assume responsibility for the processing and timely
   reimbursement of provider claims in the event that Capitated Provider fails to timely
   and accurately reimburse its claims (including the payment of interest and penalties).
   Such assumption by Plan shall be based upon: 1) a Demonstrable and Unjust Payment
   Pattern; 2) any reports required by this Amendment; 3) claim audits conducted by
   Plan or the California Department of Managed Health Care; and 4) shall be in
   accordance with the delegation provisions of the Agreement. Plan’s assumption of
   responsibility for the processing and timely reimbursement of provider claims may be
   altered to the extent that Capitated Provider has established an approved corrective
   action plan consistent with §1375.4(b)(4) of the Health and Safety Code.

8. Right to Assume Responsibility for Dispute Resolution
   Plan is authorized to assume responsibility for the administration of Capitated
   Provider’s dispute resolution mechanism and for the timely resolution of provider
   disputes in the event that Capitated Provider fails to timely resolve its provider
   disputes, including the issuance of a written decision. The terms of such assumption
   by Plan shall be based upon: 1) any reports required by this Amendment; 2) claim
   audits conducted by Plan or the California Department of Managed Health Care; and
   3) shall be in accordance with the delegation provisions of the Agreement. Plan’s
   assumption of responsibility for the processing and timely resolution of provider
   disputes may be altered to the extent that Capitated Provider has developed an
   appropriate corrective action plan, pursuant to Section 1300.71.38.(k)(3) of Title 28
   of the California Code of Regulations.

9. Controlling Language
   Except as specifically amended by this Amendment, the Agreement shall continue in
   full force and effect. Whenever the terms of the Agreement and this Amendment are
   in conflict, the terms of this Amendment shall control. All other non-conflicting
   provisions of the Agreement shall remain unchanged.




a501c35d-0cbd-4adf-89c2-0540c4e341e7.doc                                           3 of 3
ICE Approved 9-19-03                                                                        T-2

				
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Description: California Amendment to Settlement Agreement document sample