Cal. Code Regs. Tit. 22, § 58082 - Auditing and Correcting Deficiencies in Issuer Record Keeping

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(a) Within one (1) year of the first date that any Policy or Certificate holder of a particular Issuer's Policy or Certificate has met the criteria for Benefit Eligibility, and as often as the Department of Health Services deems necessary thereafter, the Department of Health Services, or its appointed designee, shall conduct a systems audit of that company's records. The Issuer shall be responsible for advising the Department of Health Services when this one (1) year period has begun. The Department of Health Services, or its appointed designee, shall inform each Issuer of inaccuracies and other potential problems discovered in its systems audits, and the Issuer shall correct any problems in its methods of operation.

(b) The Department of Health Services shall periodically reconcile a sample of individual applications for Medi-Cal of persons who have submitted documentation for qualification for the Medi-Cal Property Exemption with the reports submitted by Issuers. The Department shall have the final decision concerning sample sizes and other auditing methods. The Department of Health Services shall promptly advise Issuers of any problems discovered, and the Issuer shall correct any problems in its method of operation. The Department of Health Services shall also notify the Issuer of any obligations described in this Chapter to hold clients harmless.

(c) The Department of Health Servicers may enter into voluntary arrangements with Issuers of Partnership Long-Term Care Insurance Policies and Certificates under which the Department of Heath Services would issue binding determinations as to whether or not services qualify for a Medi-Cal Property Exemption. Requests for information and advice from Policy or Certificate holders shall be directed through their Issuer or Care Management Provider Agency. When the procedures in this section are followed, the written determinations of the Department of Health Services concerning whether services qualify for a Medi-Cal Property Exemption shall be binding upon the Department of Health Services in all subsequent actions, and the Department of Health Services shall not make any assertion contradicting these determinations in any action arising in this subsection:

(1) All requests for determinations as to whether or not services qualify for a Medi-Cal Property Exemption shall be submitted to the California Partnership for Long-Term Care in writing. These requests may include, but are not limited to, requests for determinations in the following areas:

(A) whether Benefit Eligibility has occurred and has been adequately documented;

(B) whether a revision of a Plan of Care is required;

(D) whether a service is of such a nature as to qualify for a Medi-Cal Property Exemption; and

(E) whether the applicable amount is the amount paid by the Issuer or the amount charged for the service.

(2) The California Partnership for Long-Term Care may require Issuers and Care Management Provider Agencies submitting requests for determination to provide all records and other information necessary for making a determination. The records and other information shall include, but are not limited to, the following:

(A) assessments;

(B) Plans of Care;

The Issuer providing the records and other information shall be responsible for their accuracy. If any records or other information are later determined to be materially inaccurate, the determination based on the inaccurate information shall be void and not be binding on the Department of Health Services, or any other person or entity in subsequent actions. In the case of a Policy or Certificate holder for whom a determination has been invalidated because information provided was determined to be inaccurate, the provisions of subsections (e) and (f) will apply in the same manner as for any other Policy or Certificate holder.

(3) The California Partnership on Long-Term Care shall render its determination on each request in writing within thirty (30) days of receiving the request. Each determination of the California Partnership for Long-Term Care shall state the reason(s) for it's determination, including the following:

(A) relevant facts;

(B) documentation of facts;

(D) regulations; and

(E) policies;

(4) A copy of all determinations of the California Partnership for Long-Term Care shall be kept on file at the Department of Health Services, together with the related records and information. The original of the determination shall be sent to the Issuer or the Care Management Provider Agency who originally requested it. The receipt of the original determination shall be responsible for notifying the Policy or Certificate holder or the Policy or Certificate holder's authorized agent.

(d) When an audit or other review by the Department of Health Services, or its appointed designee, reveals deficiencies in the record keeping procedures of an Issuer, the Department of Health Services will notify the Issuer of the deficiencies and establish a reasonable deadline for correction.

(e) If an Issuer prepares a Service Summary which is used in a Medi-Cal application for a Policy or Certificate holder and the client is found eligible for Medi-Cal, and the Policy or Certificate holder after receiving Medi-Cal services is found to be ineligible for Medi-Cal solely by reason of errors in the Issuer's Service Summary or documentation of services, the Department of Health Services may require the Issuer to pay for services counting towards the Medi-Cal Property Exemption required by the Policy or Certificate holder until the Issuer has paid an amount equal to the amount of the Issuer's errors; after which the Policy or Certificate holder, if otherwise eligible, could qualify for Medi-Cal coverage.

(f) If the Department of Health Services determines that an Issuer's record pertaining to a Policy or Certificate holder who has received Medi-Cal benefits are in such condition that the Department of Health Services cannot determine whether the Policy or Certificate holder qualifies for a Medi-Cal Property Exemption, the Department of Health Services may require the Issuer to pay for services counting towards the Medi-Cal Property Exemption required by the Policy or Certificate holder until the Issuer has paid an amount equal to the amount of the services which could not be determined; after which, the Policy or Certificate holder, if otherwise eligible, could qualify for Medi-Cal coverage.

(g) Compliance with subsections (e) and (f) is a requirement for a Policy or Certificate to retain certification.

Notes

Cal. Code Regs. Tit. 22, § 58082

1. New section filed 8-30-93 as an emergency; operative 8-30-93 (Register 93, No. 36). Submitted for printing only pursuant to section 22009, Welfare and Institutions Code.
2. Certificate of Compliance as to 8-30-93 order, including amendment of subsection (a), transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No. 4).
3. Amendment of subsections (a), (c) and (c)(1)(A) filed 10-1-98 as an emergency; operative 10-1-98. Submitted to OAL for printing only pursuant to Welfare and Institutions Code section 22009(d) (Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-29-99 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 10-1-98 order transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No. 12).

Note: Authority cited: Section 22009(a), Welfare and Institutions Code. Reference: Sections 22004, 22005, and 22006, Welfare and Institutions Code.

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