Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

§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.

NOTE

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

HISTORY

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).