Cal. Code Regs. Tit. 22, § 53698 - Standard of Liability

(a) The plan's financial liability to the provider, if any, shall not exceed the lower of the following rates applicable at the time the services were rendered by the provider:

(1) The usual charges made to the general public by the provider.

(2) The fee-for-service rates for similar services under the Medi-Cal program. Upon determination of the plan's liability, if no final rate has been established for a provider for the period and type of services in question, then the applicable interim rate shall be used for final determination of plan liability.

(b) The amount demanded shall be presumed to be correct, and the provider shall be entitled to the full amount demanded in its claim should it prevail, unless the plan files a Notice of Defense, pursuant to Section 53632, which places the amount of the provider's demand for payment in issue.

Notes

Cal. Code Regs. Tit. 22, § 53698

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.

1. Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No. 36).