Cal. Code Regs. Tit. 8, § 9771.75 - Reimbursements on a Fee-for-Services Basis: Determination of Status of Claims

Every organization shall institute procedures whereby all claim forms received by the organization from providers of workers' compensation health care for reimbursement on a fee-for-service basis are maintained and accounted for in a manner which permits the determination of the date of receipt of any claim, the status of any claim, the dollar amount of unpaid claims at any time, and rapid retrieval of any claim. Although any categories for status-determination held unobjectionable by the Administrative Director may be used, for the purposes of this section, the following status-determination categories, as a group, shall be presumptively reasonable:

(1) to be processed,

(2) processed, waiting for payment,

(3) pending, waiting for approval for payment or denial,

(4) pending, waiting for additional information,

(5) denied,

(6) paid, and, if appropriate,

(7) other.

These procedures shall involve the use of either a claims log, claims numbering system, electronic data processing records, and/or any other method held unobjectionable by the Administrative Director.

Notes

Cal. Code Regs. Tit. 8, § 9771.75

1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346 Section 5 (Register 98, No. 16).

Note: Authority cited: Stats. 1997, Ch. 346 Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.

1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346 , TION sec 5 (Register 98, No. 16).