Health care claims reimbursement.

Plain English Breakdown

The official source material does not explicitly state that violating the bill's provisions would be a crime or specify penalties for non-compliance. The summary mentions this but it is not clear from the provided text.

Health Care Claims Reimbursement

The bill allows health care providers up to 90 days to correct and resubmit claims that were denied or marked as overpaid due to errors.

What This Bill Does

• Gives doctors and hospitals up to 90 days to submit a corrected claim after it is denied or marked as an overpayment based on a defect that can be remedied by submitting a corrected claim.

Who It Names or Affects

• Health care providers who submit claims for payment.
• Insurance companies and health care service plans that process claims.

Terms To Know

Claim

A request from a doctor or hospital to an insurance company for money to pay for medical services given to patients.

Overpayment

When an insurance company pays more than it should for a claim, often due to errors in the paperwork.

Limits and Unknowns

• The bill does not specify what happens if a corrected claim is submitted after 90 days.
• It's unclear how this will affect existing claims that were denied before the bill was passed.

Official Summary Text

SB 1049, as amended, Weber Pierson.
Health care claims reimbursement.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to reimburse a complete claim or a portion thereof within 30 calendar days after receipt of the claim, or, if a claim or portion thereof does not meet the criteria for completeness, to notify the claimant no later than 30 calendar days after receipt that the claim or portion thereof is contested or denied.
This bill would grant a provider 90 days to submit a corrected claim after a health care service plan or health insurer denies a claim or sends a notice of
overpayment for a claim based a defect that may be remedied by submitting a corrected claim. The bill would prohibit a plan or insurer from denying a corrected claim on the grounds that the provider did not submit the claim within
the
another
applicable claim filing deadline. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

Current Bill Text

Download Bill PDF