California Health and Safety Code 1371.39 – (a) Providers may report to the department through the toll-free …
(a) Providers may report to the department through the toll-free provider line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.
(b) Plans may report to the department through the toll-free provider line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.
Terms Used In California Health and Safety Code 1371.39
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- department: means State Department of Health Services. See California Health and Safety Code 20
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- Provider: means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services. See California Health and Safety Code 1345
(c) “Unfair billing pattern” means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.
(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the review of complaint data indicates a possible unfair payment pattern, the department may conduct an audit or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.
(Amended by Stats. 2018, Ch. 303, Sec. 1. (AB 2674) Effective January 1, 2019.)