reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53407 - Door-to-Door Marketing. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14408,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53408 - Prepaid Patient Population. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53420 - Member Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 A Medi-Cal beneficiary is enrolled upon completion of all of the following
					 events:
(1) The voluntary signing and dating
					 by the Medi-Cal beneficiary of an enrollment application.
(2) Departmental validation of the
					 beneficiary's application for enrollment.
(3) Departmental verification of the
					 beneficiary's Medi-Cal eligibility.
(4) Addition of the beneficiary's name to the
					 approved list of members, furnished to the plan, which is effective at the
					 first of any given month.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53422 - Enrollment Application. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53424 - Enrollment Application Processing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall accept and submit to the
					 Department enrollment applications from all eligible Medi-Cal beneficiaries in
					 the order in which the applications were made to the plan.
(b) Unless otherwise provided in writing by
					 the Department, each plan shall accept enrollment applications from eligible
					 Medi-Cal beneficiaries to the enrollment maximums specified in the plan
					 contract.
(c) Each plan shall
					 accept enrollment applications regardless of the member's race, religion, age,
					 sex, national origin, or ancestry, and without reference to preexisting medical
					 conditions other than those specifically excluded from coverage under the plan
					 contract.
(d) Each plan shall
					 verify the accuracy of each marketing presentation according to procedures
					 established by the Department prior to submitting an enrollment application to
					 the Department for processing.
(e)
					 Each plan shall submit all enrollment applications to the Department within 15
					 days of the Medi-Cal beneficiary's signing of the application.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53426 - Term of Membership

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Except as provided in Section
						53440, membership shall continue
						indefinitely after enrollment. Membership shall be contingent upon the member's
						retention of Medi-Cal eligibility as well as eligibility for enrollment in the
						plan under the terms of the plan contract.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53440 - Disenrollment of Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Requests for disenrollment made under the following circumstances shall not be
					 processed through the plan's grievance procedure and shall be submitted to the
					 Department for processing within 5 working days after the member signs the
					 disenrollment request:
(1) The member's
					 eligibility as a Medi-Cal beneficiary for enrollment in the plan is
					 terminated.
(2) The enrollment is
					 in violation of Sections
					 53400,
					 53401,
					 53401.1,
					 53402,
					 53404 or
					 53406.
(3) The request for disenrollment is pursuant
					 to Sections
					 53508 and
					 53510.
(4) Change of a member's place of residence
					 outside the plan's service area.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53442 - Disenrollment Requests

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Members desiring disenrollment shall make their requests to an authorized
					 representative of the plan, on forms prescribed by the Department, or to the
					 Department.
(b) Plans shall furnish
					 disenrollment request forms to members immediately upon request by the member.
					 Disenrollment request forms shall be mailed to a member if requested.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Amendment filed 9-22-82; effective thirtieth day thereafter
						(Register 82, No. 39).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14303.1,
						  14303.2,
						  14409,
						  14412,
						  14413
						  and
						  14450,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53450 - Information to New Enrollees

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each Medi-Cal beneficiary signing an
					 enrollment application shall be informed in writing of the following:
(1) A 15 to 45-day processing period is
					 necessary between the date of application and receipt by the plan of written
					 notice from the Department that the applicant has been enrolled.
(2) Enrollment is not effective until such
					 processing is completed.
(3) The
					 applicant has the right to receive health care services under his/her current
					 arrangement during the processing period, so long as he/she retains Medi-Cal
					 eligibility.
(4) The applicant has
					 the right to request disenrollment without cause at any
					 time.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53452 - Information to New Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan shall provide, in writing, in addition to those
						items of information required by Section
						14406,
						Welfare and Institutions Code, the following to each member within seven days
						after the effective date of enrollment:
(a) The effective date of enrollment and the
					 term of enrollment.
(b) A
					 description of all available services and an explanation of any service
					 limitations, exclusions from coverage or charges for services when
					 applicable.
(c) The name, telephone
					 number and service site address of the primary care physician chosen by or
					 otherwise made available to the member.
(d) The appropriate use of health care
					 services and the contributions the member can make toward the maintenance of
					 the member's own health.
(e)
					 Information concerning transportation arrangements offered by the
					 plan.
(f) An explanation of the
					 member's right to request a fair hearing under Welfare and Institutions Code
					 Section
					 10950,
					 et seq. for unresolved grievances and to request a fair hearing without going
					 through the plan's grievance procedures when a health care service requested by
					 the member or a provider has not been provided.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Amendment filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
3. Repealer of subsection (a) designator,
						subsection relettering, new subsection (f) and amendment of NOTE filed
						10-17-95; operative 11-16-95 (Register 95, No.
						42).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  10950,
						  14406
						  and
						  14450,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53454 - Annual Information to Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan shall revise, if necessary, and distribute the
						information specified in Section
						53452(b) to each
						member or the member's family unit at least once every 12
						months.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53456 - Notification of Changes in Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan shall revise and distribute the information
						specified in Section
						53452(b) at least
						14 days prior to any changes which the plan makes in services provided or in
						the locations at which services may be obtained to each member affected by such
						change. Notification shall be provided as soon as possible in cases of
						unforeseen circumstances.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53458 - Information for Departmental Dissemination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan shall furnish the Department, upon request, the
						information required in Section
						53452(b) for
						dissemination to prospective members.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53502 - Rejection of Contract Applications

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Director may reject applications for
					 the establishment of a plan contract for any reason, including but not limited
					 to:
(1) Failure of the organization to submit,
					 to the satisfaction of the Department, any of the information required by
					 Section 53500.
(2) Failure of the organization to
					 satisfactorily demonstrate to the Department its intent and ability to comply
					 with the terms and conditions of the contract and with all applicable laws and
					 regulations.
(3) Presentation of
					 evidence at a public hearing held in accordance with Section
					 14300,
					 Welfare and Institutions Code, that the organization has not complied with, or
					 will not be able to comply with, its contractual obligations.
(4) Evidence that the contract should not be
					 entered into or renewed pursuant to Section
					 53600.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53504 - Effect and Term of Contracts. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment of subsection (c) filed 7-5-78; effective thirtieth day thereafter
						(Register 78, No. 27).
2. Repealer filed 12-20-81; effective
						thirtieth day thereafter (Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14251
						  and
						  14302,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53506 - Contract Renewals

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
					 plan contract shall be renewed unless good cause is shown for nonrenewal. Good
					 cause for nonrenewal shall include, but not be limited to, the following:
(1) Failure of the plan to comply with all
					 terms and conditions of the contract and with all applicable laws and
					 regulations.
(2) Failure of the
					 plan to comply with the provisions of a renewed contract and all applicable
					 laws and regulations.
(3) The
					 Department's finding of fact, based upon the plan's past performance under its
					 contract, that it does not have the ability to fulfill the terms of a renewed
					 contract with the State.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53508 - Mergers or Reorganizations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department may approve plan contract
					 amendments relating to mergers or reorganizations if, in addition to satisfying
					 the conditions of Section
					 14303.1
					 or
					 14303.2,
					 Welfare and Institutions Code as applicable, the following conditions are
					 satisfied:
(1) The surviving organization
					 meets the requirements of Section
					 53124.
(2) The information required by Section
					 53500 is submitted for the
					 surviving organization.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53510 - Reorganizations and Intraplan Mergers. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50). For prior history, see Register 78, No. 27.
2. Amendment filed
						9-22-82; effective thirtieth day thereafter (Register 82, No.
						39).
3. Repealer filed 10-26-84; effective thirtieth day thereafter
						(Register 84, No. 43).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14300
						  and
						  14303.2,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53518 - Prehearing Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each prepaid health plan submitting a proposal for an initial contract and each
					 plan wishing to renew its contract or merge with another plan shall submit a
					 formal proposal pursuant to Section
					 53500 to the Department at least
					 150 days prior to the date of the initial contract, renewal or
					 merger.
(b) The Department shall
					 complete its review of the proposal within 30 days after its receipt. The
					 Department shall notify the plan within 30 days after receipt of the proposal
					 of any deficiencies in the proposal. The plan shall supply any additional
					 information requested by the Department in the deficiency notification within
					 15 days after notification of deficiencies by the Department.
(c) The Department shall publish a public
					 notice in accordance with the provisions of Section
					 53520.
(d) At least five working days prior to the
					 date of a public hearing, the Department shall make available to the plan and
					 to the public all information which it intends to present at the hearing. This
					 information shall be provided directly to the plan. In addition, information
					 shall be made available to the public by making one or more copies available
					 for public inspection in a public building within the service area of the plan.
					 The location of such public building and the availability of such information
					 shall be included in the notice of public hearing sent to plan members and to
					 interested members of the general public.
1.
						Amendment filed 9-22-82; effective thirtieth day thereafter (Register 82, No.
						39).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14300,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53520 - Public Notice and Public Hearings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall publish a public
					 notice at least 120 days prior to:
(1)
					 Entering into an initial or renewed contract.
(2) Amending an existing contract for the
					 purpose of:
(A) Reducing the scope or
					 availability of services provided by the prepaid health plan.
(B) Enlarging the service area of the prepaid
					 health plan.
(C) Increasing the
					 maximum enrollment permitted under the contract.
(D) Making any other change in the plan's
					 organization, operation or delivery of services which, in the Department's
					 estimation, will have a substantial impact on the ability of enrollees to
					 obtain health care services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53522 - Public Hearing Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Department shall prepare the agenda for the hearing and an informational
					 attachment to the agenda, translated into languages appropriate to the plan's
					 actual or potential membership. The informational summary shall serve to
					 provide the public hearing audience with background material on the
					 plan.
(b) Each public hearing shall
					 be presided over by a duly authorized hearing officer.
(c) The hearing officer shall present an oral
					 statement designed to inform the public of the authority and purpose for
					 holding the hearing, to explain how the hearing will be conducted, to provide
					 the public with directions on presenting testimony and to solicit testimony
					 from the public.
(d) Departmental
					 management, fiscal and medical audit information on the plan shall be
					 introduced at the hearing. A representative from the Department shall introduce
					 and summarize all of the documents to be entered into the public hearing record
					 by the Department.
(e) The plan's
					 representative shall introduce and summarize any documentation which it desires
					 to have entered into the public hearing record. All charts and other
					 presentation material shall be in a size or format specified by the
					 Department.
(f) Public input from
					 the audience shall be made on the basis of the order in which an identification
					 card for persons wishing to make a presentation is received by the hearing
					 officer. All persons wishing to testify or ask questions shall be afforded that
					 opportunity. The plan and the Department shall have a sufficiently broad
					 representation of personnel in attendance to answer questions asked by
					 interested parties.
(g) Witnesses
					 at the hearing shall not be subject to questioning except under the following
					 conditions:
(1) Representatives of the plan
					 shall be subject to questioning by representatives of the Department. In
					 addition, members of the public may direct questions to representatives of the
					 plan under such conditions and pursuant to such procedures as may be determined
					 by the hearing officer.
(2)
					 Representatives of the Department shall be subject to questioning by
					 representatives of the plan. In addition, members of the public may direct
					 questions to representatives of the Department under such conditions and
					 pursuant to such procedures as may be determined by the hearing
					 officer.
(3) Expert witnesses
					 giving testimony either favorable or unfavorable to the plan may be subject to
					 questioning under such conditions and pursuant to such procedures as may be
					 determined by the hearing officer.
(4) The hearing officer may ask questions of
					 any person giving testimony.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 6 - CONFLICT OF INTEREST › Section 53600 - Prohibitions Against Contracting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A plan contract shall not be approved or
					 renewed by the Department if any state officer or state employee or his spouse
					 or his minor children has a substantial financial interest in (1), (2) or (3).
					 For the purposes of this subsection, state employee includes any Department
					 employee in an analyst, auditor or medical personnel classification who has
					 direct responsibility for the negotiation, development or management of a
					 prepaid health plan contract.
(1) The
					 contract or the contracting organization.
(2) Any contract with the contracting
					 organization.
(3) Procurement of a
					 contract for the contracting organization.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 6 - CONFLICT OF INTEREST › Section 53601 - Disclosure Statements. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 10-11-85; effective thirtieth day thereafter
						(Register 85, No. 41).
Note: Authority cited: Sections
						  14124.5
						  and
						  1431,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53620 - General Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The provisions of this article shall establish the procedures for Department
					 resolution of disputes concerning payment for emergency services rendered by
					 non-plan providers to prepaid health plan members who are Medi-Cal
					 beneficiaries.
(b) The procedures
					 established in this article may be used to resolve disputes which meet all of
					 the following requirements:
(1) Arise out of
					 services rendered after September 28, 1977.
(2) Have not previously been resolved and are
					 not presently the subject of litigation or arbitration.
(3) Involve plans with current, active
					 contracts with the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53622 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The following
					 definitions shall govern the construction of this article unless the context or
					 subject matter otherwise requires:
(1) "Day"
					 means a calendar day.
(2) "Dispute"
					 means a dispute concerning payment for care under emergency circumstances
					 provided to plan members by nonplan providers.
(3) "Emergency services" or "care under
					 emergency circumstances" means those health care services required for
					 alleviation of severe pain or immediate diagnosis and treatment of unforeseen
					 medical conditions which if not immediately diagnosed and treated would lead to
					 disability or death. Such emergency is deemed to continue until:
(A) In reasonable medical judgment, the
					 patient's condition has stabilized sufficiently so as to permit either:
(1) Discharge, or
(2) Referral and transfer of the patient, in
					 accordance with instructions from the patient's plan, to such level of
					 treatment or care as may be appropriate, and
(B) A reasonable time within which to
					 complete such discharge, or referral and transfer.
(4) "Party" means the provider, the plan or
					 any person, other than an officer or employee of the Department acting in an
					 official capacity, who has been allowed to appear in the proceeding.
(5) "Provider" means a nonplan provider who
					 files a claim against a plan for emergency services in accordance with this
					 article.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53624 - Claims Filing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
					 provider may submit a dispute to the Department by filing a claim accompanied
					 by a copy of the proof of service of the claim on the plan.
(b) A claim and proof of service shall be
					 filed within 120 days after the dispute arose.
(c) For the purposes of this article, a
					 dispute is deemed to arise upon the occurrence of the earlier of the following
					 events:
(1) A plan sends notice of rejection
					 or reduction of a demand for payment for care under emergency circumstances. In
					 this case, the dispute arises on receipt of the notice by the
					 provider.
(2) A plan fails to pay a
					 demand for payment for care under emergency circumstances within 60 days after
					 the demand was properly mailed to the plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53626 - Filing and Service

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All
					 papers shall be filed at the State Department of Health Care Services, Office
					 of Administrative Hearings and Appeals, 3831 N. Freeway Blvd., Suite 200,
					 Sacramento, CA 95834, and shall be deemed filed as of the postmark date, or
					 receipt by the Department, if no legible postmark is provided.
(b) Service may be accomplished and proved
					 by:
(1) Ordinary mail, postage fully prepaid,
					 and the execution of a declaration of service by mail, made under penalty of
					 perjury.
(2) Any means authorized
					 by law for use in civil actions.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53628 - Claim Content

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 claim shall be entitled "Emergency Services Claim" and shall contain the
					 following information:
(1) The full name of
					 the patient and whether such patient was a Medi-Cal beneficiary during the
					 period of service.
(2) The title,
					 name, and address of both the provider and the provider's authorized
					 representative if any.
(3) The name
					 and address of the prepaid health plan of which the patient was a member during
					 the period of treatment, together with the present name and address of the
					 plan.
(4) The period of treatment
					 for which payment is requested.
(5)
					 The date the dispute arose and the facts establishing such date pursuant to
					 Section 53624.
(6) The total amount claimed for the services
					 provided.
(7) A statement that a
					 demand upon the plan for payment for such services has been made by the
					 provider, and the date and method of transmission of such demand.
(8) A statement setting forth all facts
					 supporting the contention that the treatment given was an emergency service
					 within the meaning of Section
					 53622. A mere statement that an
					 emergency existed is not sufficient.
(9) A statement of facts showing that the
					 patient could not have been transferred to the care of the prepaid health plan
					 during the period claimed.
(10) A
					 statement that the dispute has not previously been resolved, is not the subject
					 of pending litigation, arbitration, or billing to Medi-Cal.
(11) A statement that the provider has
					 supplied to the plan copies of all medical records or other supporting
					 documents on which the provider relies, in accordance with paragraph
					 (d).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53630 - Dismissal After Notice of Defective Claim

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing officer shall notify the
					 provider of any defects if the hearing officer finds that the claim fails to
					 conform with the requirements of Sections
					 53620,
					 53624, and
					 53628. The provider shall have 60
					 days from the date of mailing of the notice within which to file and serve a
					 corrected claim. The claim shall be dismissed upon the provider's failure to
					 file a timely corrected claim with proof of service.
(b) A claim shall not be dismissed for the
					 late filing or service if, prior to the issuance of a decision in the matter:
(1) The provider shows good cause for the
					 late filing or service.
(2) The
					 parties have stipulated in writing that the time may be
					 extended.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53632 - Notice of Defense

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 plan shall file a response entitled, "Notice of Defense" which shall:
(1) Admit or deny, in whole or in part, each
					 numbered portion of the claim. Matters not denied are deemed admitted. Denials
					 may be based on a lack of information sufficient to identify the transaction or
					 prepare a defense.
(2) Introduce
					 new information in defense of the plan's position, if any.
(3) State the reasons for rejecting the
					 claim.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53634 - Defaults

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Failure to file
					 a timely Notice of Defense and to serve a copy on the provider or failure to
					 appear at a hearing shall be deemed a default and a waiver of the defaulting
					 party's right to a hearing unless, prior to decision in the matter:
(1) The party shows good cause for the
					 failure.
(2) All parties have
					 stipulated in writing that the failure shall not be deemed a
					 default.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53636 - Amended or Supplemental Claims

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The provider may file and serve an
					 amended or supplemental claim within 90 days of the original filing date,
					 except where dismissal has been entered pursuant to Section
					 53630.
(b) The plan shall be given 45 days to file a
					 response to any amended or supplemental claim.
1.
						Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53638 - Consolidation of Claims

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 hearing officer may consolidate claims for hearing and decision involving the
					 same parties upon notice to all parties, if parties agree or if no substantial
					 right of any party will be prejudiced.
(b) When claims have been consolidated:
(1) A consolidated hearing may be
					 held.
(2) A single record of the
					 proceedings shall be made.
(3)
					 Evidence introduced in one claim may be considered as introduced in the
					 others.
(4) Separate or
					 consolidated decisions shall be made, as appropriate.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53640 - Additional Parties

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The hearing officer may join other persons, upon their
						consent, as parties to the proceeding in order to resolve the issues and to
						render a decision. The hearing may be continued as necessary.
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53642 - Withdrawal or Settlement of Claim

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The provider may, by written request,
					 withdraw a claim at any time prior to issuance of a decision. The hearing
					 officer shall then issue a notice to the parties dismissing the
					 claim.
(b) The parties may enter
					 into a stipulated agreement settling the claim at any time prior to issuance of
					 a decision. The stipulated agreement, signed by the parties, shall be submitted
					 in writing to the hearing officer, who shall issue a decision and order, in
					 accordance with Section
					 53691.
(c) Relief, in accordance with Section
					 53696, from a decision or order of
					 settlement or dismissal, shall result in the reinstatement of a previously
					 withdrawn or settled claim.
1.
						Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53644 - Discovery. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53646 - Submissions. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53648 - Nondisclosure. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53650 - Expedited or Deferred Proceedings. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53651 - Small Claims Procedure. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53652 - Request for Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Within 20 days after the filing of a Notice of Defense, any party may file a
					 request for a hearing. Each party may appear before the hearing officer,
					 personally or by representative, and participate in the hearing if any party
					 files a timely request for hearing.
(b) Each party shall be deemed to have waived
					 the right to a hearing if a timely request for a hearing is not filed. The
					 hearing officer may proceed to render a decision upon the written record, as
					 provided in Section
					 53654.
(c) Where a hearing has not been requested,
					 one may still be held upon a proper showing of good cause or at the discretion
					 of the hearing officer.
1.
						Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53654 - Decision on Written Record

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing officer may render a proposed
					 decision based on the record if all of the parties have waived their right to
					 oral hearing.
(b) The hearing
					 officer shall make a record of the relevant written evidence and argument. The
					 parties, within the time limit specified by the hearing officer, may submit
					 additional written argument and evidence.
(c) Such written evidence shall be considered
					 as all of the evidence in the proceeding, and the decision shall be based
					 thereon subject to the procedure set forth in Section
					 53692.
1.
						Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53656 - Prehearing and Posthearing Conferences

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing officer may order the holding
					 of prehearing or posthearing conferences for the purpose of facilitating the
					 disposition of the proceeding. Attendance may be by telephone conference
					 call.
(b) The hearing officer may
					 preside at the conference or may assign responsibility for the conduct of the
					 conference to the medical consultant assigned to the hearing. Agreements and
					 actions resulting from the conference shall become part of the hearing record
					 and be binding upon all parties.
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53658 - Notice of Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 hearing officer shall schedule the matter for hearing upon the timely
					 application of any party, or upon the hearing officer's own motion. Notice of
					 hearing shall be served upon all parties at least 15 days prior to the date of
					 the hearing unless the parties:
(1) Consent to
					 shorter notice.
(2) Waive
					 notice.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53660 - Time and Place of Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Department shall determine the time and place of hearing. The scheduling of
					 time and place of hearing shall be subject to the availability of Department
					 staff.
(b) The hearing shall be
					 held as soon as reasonably possible after any request for hearing, in
					 accordance with Section
					 53652.
1.
						Amendment filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53662 - Witnesses and Subpoenas

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each party shall arrange for the appearance of the
						witnesses called by that party. Subpoenas and subpoenas duces tecum shall be
						issued by the hearing officer in accordance with Section
						11510,
						Government Code.
1.
						Amendment filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53664 - Depositions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing
					 officer, on application of any party, may order the deposition of a witness to
					 be taken for use as evidence, but not for discovery, if:
(1) The witness cannot be compelled to attend
					 the hearing.
(2) Other
					 circumstances warrant such action.