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Meritage Medical Network Claims Department Policy Statement

Subject:

AB 1324 Treatment Authorization Legislation

Effective Date:

01/01/2008

Reviewed/Revised:

12/2008

Policy:

The Meritage Medical Network as a delegated provider organization is required to comply with applicable state and federal laws pertaining to claims processing for health maintenance organizations.

HMOs are regulated by the Department of Managed Health Care and are required to comply with California Assembly Bill 1324

Description:

Assembly Bill 1324 prohibits retroactively rescinding or modifying an authorization for services with dates of service on or after January 1, 2008 where services have already been rendered.

The law states that when a health plan or its delegated medical group has authorized a specific type of treatment, it cannot rescind or modify the authorization, or deny applicable reimbursement for the treatment authorized after the provider renders treatment in good faith pursuant to the authorization, based solely on the plan’s subsequent rescission, retroactive cancellation or retroactive modification of the member’s contract.

Under certain circumstances, (and only with the approval of the Director of Claims) the Meritage Medical Network will allow reimbursement for authorized services even when it is later determined that the member is no longer eligible.

The authorized provider must meet all of the following criteria with regards to reimbursement for authorized services when the patient is no longer eligible:

  • The authorization was issued on or after 01/01/2008 and
  • The authorized provider delivered the service and
  • Provider can prove that he/she verified member eligibility within 5 business days of the service
  • Provider can demonstrate he/she has been unsuccessful in collecting from the member or the subsequent carrier.

Each case will be reviewed and handled as a provider dispute. Consideration will only be given to:

  • The actual authorized provider and
  • The actual services listed on the original authorization.

Additional services not included in the authorization but routinely billed by providers as supplemental or incidentals do not qualify for reimbursement.