Cal. Code Regs. Tit. 22, § 53628 - Claim Content
(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).
(b) Legible copies
of the following documents shall, if in provider's possession or under
provider's control, be submitted as attachments to the claim:
(1) A copy of any document from the prepaid
health plan rejecting or reducing the provider's demand;
(2) A copy of the provider's demand for
payment itemizing the services provided.
(3) A copy of the proof of service required
by Section
53624.
(c) The claim shall:
(1) Be dated and signed by the provider or
the provider's authorized representative.
(2) Designate an individual and an address
for the service of any and all papers relating to proceedings conducted under
this article.
(d) The
provider shall attach copies of all medical records, or other supporting
documents on which the provider relies, to the copy of the claim which the
provider serves upon the plan in accordance with Section
53624.
Notes
Note: Authority cited: Sections 14312 and 14454, Welfare and Institutions Code. Reference: Section 14454, Welfare and Institutions Code.
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