Health care claims reimbursement.

Plain English Breakdown

The official source material does not provide details on whether making violations a crime will require local agencies to follow new state rules or if it explicitly states that no reimbursement is required by the act.

Health Care Claims Reimbursement Rules

The bill extends the deadline from 30 days to 90 days for health care providers to resubmit corrected claims after their original claims are denied or marked as overpaid by health plans or insurers.

What This Bill Does

• Extends the deadline from 30 days to 90 days for a provider to submit a corrected claim if it was initially denied due to errors that can be fixed.
• Prevents health care service plans and insurers from rejecting corrected claims just because they were submitted after the original deadline.

Who It Names or Affects

• Health care providers who submit claims to health plans or insurers.
• Health care service plans and insurance companies that process these claims.

Terms To Know

Provider

A doctor, hospital, or other health care professional who treats patients and submits bills for payment.

Claim

A request by a provider to be paid for services given to a patient.

Limits and Unknowns

• The bill does not specify the consequences if providers miss the new 90-day deadline.
• It is unclear how many local agencies will need to change their practices based on this law.
• The bill has passed both chambers of the California Legislature but its final status, including whether it becomes a law, is still unknown.

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