Section: II
Last Review Date: 8/26/02, 12/31/03, 10/12/04,
12/15/05, 12/28/06, 9/27/07
Department: Claims
Operating Unit: ValueOptions of California, Inc.
Approval Signatures:
Leanne Mulford
VOC Claims Liaison
I.
II.
Original Date of Issue:
01/01/01
Date(s) Revised: 01/01/01, 8/26/02, 12/31/03
Subject: Emergency Claims
Page 1 of 7
Available Upon Request
Hal Levine, D.O.
Interim Medical Director
Purpose
A.
To establish ValueOptions of California Inc. (“VOC” or the “Plan”) policies and
procedures for receipt, review, and completing the accurate and timely
adjudication of claims for emergency care and services and urgent care services.
This policy and procedure is utilized for the Plan’s Knox-Keene approved Mental
Health/Substance Abuse (MHSA) benefit plans. This policy does not apply to the
Employee Assistance Program (“EAP”) as emergency services and care is not a
covered benefit under EAP benefit plans.
B.
To ensure compliance with the requirements of Sections 1371.35, 1371.8,
1399.55, and 1399.56 of the California Knox-Keene Health Care Service Plan Act
of 1975 as amended, Section 1317.1 of the California Health and Safety Code,
and Rules 1300.71, 1300.71.38, 1300.71.4 and 1300.77.4 of Title 28 of the
California Code of Regulations. These regulatory requirements are enforced by
the Department of Managed Health Care (“DMHC”).
C.
Except where the guidelines in this policy specify otherwise, claims for
emergency care and services are also subject to the same guidelines for review
and processing of claims not involving emergency care and services, see policy #
CL002P (Timely Claims Processing). Providers may also submit disputes related
to claims involving emergency services and such disputes must be handled
according to the Plan policy # CSC204P.
Departments(s) and Committee(s) Affected:
A.
B.
C.
D.
E.
III.
Number: CL007.VOC
Policy
Claims Department
Claims Customer Service
Finance Department
Provider Dispute staff
QM Committee
Section: II
Last Review Date: 8/26/02, 12/31/03, 10/12/04,
12/15/05, 12/28/06, 9/27/07
Department: Claims
Operating Unit: ValueOptions of California, Inc.
Approval Signatures:
Leanne Mulford
VOC Claims Liaison
Number: CL007.VOC
Original Date of Issue:
01/01/01
Date(s) Revised: 01/01/01, 8/26/02, 12/31/03
Subject: Emergency Claims
Page 2 of 7
Available Upon Request
Hal Levine, D.O.
Interim Medical Director
A.
The Plan will reimburse each complete claim, or portion thereof, whether in state
or out of state, as soon as practical, but no later than 30 working days after receipt
of the complete claim by the Plan.
B.
The Plan may contest or deny a claim, or portion thereof, by notifying the
claimant, in writing, that the claim is contested or denied, within 30 working days
after receipt of the claim by the Plan.
1.
The notice that a claim, or portion thereof, is contested will identify the
portion of the claim that is contested, by revenue code, and the specific
information needed from the provider to reconsider the claim.
2.
The notice that a claim, or portion thereof, is denied will identify the
portion of the claim that is denied, by revenue code, and the specific
reasons for the denial. The Plan may delay payment of an uncontested
portion of a complete claim for reconsideration of a contested portion of
that claim if the Plan pays those charges specified in section “C” below.
C.
If a complete claim or portion of the claim, that is neither contested nor denied, is
not reimbursed by delivery to the claimant's address of record within 30 working
days after receipt, the Plan must pay the greater of fifteen dollars ($15) per year or
interest at the rate of 15 percent per annum beginning with the first calendar day
after the 30 working day period. The Plan must automatically (see definition in
CL008P) include the fifteen dollars ($15) per year or interest due in the payment
made to the claimant, without requiring a request from the claimant. Refer to
policy # CL008P “Commercial Interest Payment” for the instructions on how to
calculate interest amounts.
D.
If a claim or portion thereof is contested on the basis that the Plan has not
received information reasonably necessary to determine payer liability for the
claim or portion thereof, then the Plan has 30 working days after receipt of this
additional information to complete reconsideration of the claim. If a claim, or
portion thereof, undergoing reconsideration is not reimbursed by delivery to the
claimant's address of record within 30 working days after receipt of the additional
information, the Plan shall pay the greater of fifteen dollars ($15) per year or
interest at the rate of 15 percent per annum beginning with the first calendar day
Section: II
Last Review Date: 8/26/02, 12/31/03, 10/12/04,
12/15/05, 12/28/06, 9/27/07
Department: Claims
Operating Unit: ValueOptions of California, Inc.
Approval Signatures:
Leanne Mulford
VOC Claims Liaison
Number: CL007.VOC
Original Date of Issue:
01/01/01
Date(s) Revised: 01/01/01, 8/26/02, 12/31/03
Subject: Emergency Claims
Page 3 of 7
Available Upon Request
Hal Levine, D.O.
Interim Medical Director
after the 30 working day period. The Plan will automatically include the fifteen
dollars ($15) per year or interest due in the payment made to the claimant,
without requiring a request from the claimant. Refer to policy #CL008P
“Commercial Interest Payment” for the instructions on how to calculate interest
amounts.
E.
The timeframe and interest requirements in this policy do not apply to claims
when there is evidence of fraud and misrepresentation, to eligibility
determinations, or in instances where the Plan has not been granted reasonable
access to information under the provider's control. In one these exception cases,
the Plan will send a written notice sent to the provider within 30 working days of
receipt of the claim identifying which of these exceptions applies to a claim.
F.
The Plan will not delay payment on a claim from a physician or other provider to
await the submission of a claim from a hospital or other provider, without citing
specific rationale as to why the delay was necessary. The Plan will provide a
monthly update regarding the status of such a claim and the Plan's actions to
resolve the claim, to the provider that submitted the claim.
G.
It is the Plan’s policy not to require prior authorization for emergency or out of
area urgent care. However, the claim system has been designed to check for
authorization prior to adjudication for those times when a contracted provider
may have requested approval prior to sending a member for services, or an
authorization has been entered prior to receipt of the claim. Claims for out of area
and in area urgent care services are to be reviewed following the same guidelines
as emergency room claims.
(See policy CL002P Timely Claims Processing and Policy CSC204P Provider Dispute
Resolution Mechanism for more information related to claims and dispute requirements.)
IV.
Definitions
A.
Complete claim means a claim or portion thereof, if separable, including
attachments and supplemental information or documentation, which provides:
“reasonably relevant information” and “information necessary to determine payer
Formatted: Bullets and Numbering
Section: II
Last Review Date: 8/26/02, 12/31/03, 10/12/04,
12/15/05, 12/28/06, 9/27/07
Department: Claims
Operating Unit: ValueOptions of California, Inc.
Approval Signatures:
Leanne Mulford
VOC Claims Liaison
Number: CL007.VOC
Original Date of Issue:
01/01/01
Date(s) Revised: 01/01/01, 8/26/02, 12/31/03
Subject: Emergency Claims
Page 4 of 7
Available Upon Request
Hal Levine, D.O.
Interim Medical Director
liability” as defined in the Definitions section of policy # CL002P (Timely Claims
Processing), and:
1.
For emergency services and care provider claims as defined by Section
1371.35(j) of the Knox-Keene Act (Refer to the definitions in sections B
and C below for these cited definitions):
a. The information specified in Section 1371.35(c) of the Health and
Safety Code; and
b. Any state-designated data requirements included in statutes or
regulations.
2.
Section 1371.35(c) specifies the following information: A claim, or
portion of thereof, is reasonably contested if VOC has not received the
completed claim as described below.
a. A paper claim from an institutional provider shall be deemed complete
upon submission of a legible emergency department report and a
completed UB 92 or other format adopted by the National Uniform
Billing Committee, and reasonable relevant information requested by
the Plan within 30 working days of receipt of the claim.
b. An electronic claim from an institutional provider shall be deemed
complete upon submission of an electronic equivalent to the UB 92 or
other format adopted by the National Uniform Billing Committee, and
reasonable relevant information requested by the Plan within 30
working days of receipt of the claim.
i. However, if the Plan requests a copy of the emergency department
report within the 30 working days after receipt of the electronic
claim from the institutional provider, the Plan may also request
additional reasonable relevant information within 30 working days
of receipt of the emergency department report, at which time the
claim must be considered complete.
Section: II
Last Review Date: 8/26/02, 12/31/03, 10/12/04,
12/15/05, 12/28/06, 9/27/07
Department: Claims
Operating Unit: ValueOptions of California, Inc.
Approval Signatures:
Number: CL007.VOC
Original Date of Issue:
01/01/01
Date(s) Revised: 01/01/01, 8/26/02, 12/31/03
Subject: Emergency Claims
Page 5 of 7
Available Upon Request
Hal Levine, D.O.
Interim Medical Director
Leanne Mulford
VOC Claims Liaison
c. A claim from a professional provider shall be deemed complete upon
submission of a completed HCFA 1500 or its electronic equivalent or
other format adopted by the National Uniform Billing Committee, and
reasonable relevant information requested by the Plan within 30
working days of receipt of the claim.
i.
The provider shall provide the Plan reasonable relevant
information within 10 working days of receipt of a written request
that is clear and specific regarding the information sought.
ii.
If, as a result of reviewing the reasonable relevant information, the
Plan requires further information, the Plan has an additional 15
working days after receipt of the reasonable relevant information
to request the further information at which time the claim is
deemed complete.
B.
Emergency Medical Or Behavioral Condition: A medical or behavioral
condition, the onset of which is sudden, that manifests itself by symptoms of
sufficient severity, including severe pain, that a prudent layperson possessing an
average knowledge of medicine and health, could reasonably expect the absence
of immediate medical attention to result in (1) placing the health of the person
affected with such condition in serious jeopardy, or in the case of a behavioral
condition, placing the health of the persons or others in serious jeopardy; or (2)
serious impairment to such person’s bodily functions; or (3) serious dysfunction
of any bodily organ or part of such person; or (4) serious disfigurement of such
person.
C.
Emergency Services and Care: Means those covered services provided for
screening, examination, and evaluation by a physician, or other personnel to the
extent permitted by applicable law and within the scope of their licensure and
clinical privileges, to determine if a psychiatric emergency medical condition
exists, and the care and treatment necessary to relieve or eliminate the psychiatric
emergency medical condition, within the capability of the facility.
1.
Medically Necessary ambulance and ambulance transport services
provided through the 911 emergency response system also qualify as
Section: II
Last Review Date: 8/26/02, 12/31/03, 10/12/04,
12/15/05, 12/28/06, 9/27/07
Department: Claims
Operating Unit: ValueOptions of California, Inc.
Approval Signatures:
Leanne Mulford
VOC Claims Liaison
Number: CL007.VOC
Original Date of Issue:
01/01/01
Date(s) Revised: 01/01/01, 8/26/02, 12/31/03
Subject: Emergency Claims
Page 6 of 7
Available Upon Request
Hal Levine, D.O.
Interim Medical Director
emergency services and care and claims for such ambulance services must
be processed according to the guidelines in this policy.
(See policy CL002P Timely Claims Processing for additional definitions)
V.
Procedure
A.
Claims for emergency services or urgent care are researched and adjudicated in
the same manner as claims for routine services as described in policy CL002P.
The steps below describe some of the specific review circumstances applicable to
emergency services and urgent care claims.
B.
Claims received for emergency or urgent care services are reviewed for prior
existence of an authorization. An authorization would include:
1.
A contracted provider refers the member,
2.
A contracted provider’s answering service refers the member to an
Emergency Room or Urgent Care,
3.
Any time services are received as a result of VOC staff directing members
to call 911 or go to an emergency room.
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C.
A referral made by any of the above sources will result in payment.
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D.
If no authorization is in the system:
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1.
The processor will look at the admitting diagnosis and compare it to the
list of automatically approved diagnosis codes. If the diagnosis is on the
list, the processor will continue with the payment process.
2.
If the diagnosis is not on the auto-pay list, the processor is to determine by
means of a call, if a contracted physician or other source (see section B
above) referred the member.
3.
If either of the above is met, proceed with payment process.
Section: II
Last Review Date: 8/26/02, 12/31/03, 10/12/04,
12/15/05, 12/28/06, 9/27/07
Department: Claims
Operating Unit: ValueOptions of California, Inc.
Approval Signatures:
Leanne Mulford
VOC Claims Liaison
Number: CL007.VOC
Original Date of Issue:
01/01/01
Date(s) Revised: 01/01/01, 8/26/02, 12/31/03
Subject: Emergency Claims
Page 7 of 7
Available Upon Request
Hal Levine, D.O.
Interim Medical Director
E.
If the admitting diagnosis is not on the list for auto pay, the claim will be routed
to the Medical Director for review.
F.
The Medical Director will review the claim and any supporting documentation to
make a determination. If the services rendered, or admitting diagnosis or
symptoms as reported by the patient meet the definitions in section IV.B and C
above, the Medical Director will approve the claim, document the decision and
return the claim to the processor, who will continue to adjudicate the claim
following the process in CL002P.
G.
If the Medical Director denies the claim based on medical necessity reasons, the
denial reason will be documented and the claim returned to the processor. The
processor will then complete the claim adjudication process and a denial will be
issued on a Provider Summary Voucher and Explanation of Benefits statement. A
claim for emergency services may not be denied with a reason stating there
was no prior authorization.
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