California Health and Safety Code

§ 1371.35

HSC § 1371.35 Effective Jan 1, 2025Div. 2 · Ch. 2.2 · Art. 5

Statute text

(a)(1) A health care service plan, including a specialized health care service plan, shall reimburse a complete claim or portion thereof, whether in state or out of state, as soon as practicable, but no later than 30 calendar days after receipt of the claim by the health care service plan. If a claim or portion thereof does not meet the criteria for a complete claim or the criteria for coverage under the plan contract, a health care service plan shall notify the claimant, in writing, that the claim or portion thereof is contested or denied, as soon as practicable, but no later than 30 calendar days after receipt of the claim by the health care service plan.

(2)The notice that a claim or portion thereof, is contested shall identify the portion of the claim that is contested, by procedure or revenue code, and the specific information needed from the provider to reconsider the claim, including any defect or impropriety or additional information needed to adjudicate the claim.

(3)The notice that a claim or portion thereof, is denied shall identify the portion of the claim that is denied, by procedure or revenue code, and the specific reasons for the denial, including any defect or impropriety.

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Legislative history

Repealed (in Sec. 4) and added by Stats. 2024, Ch. 763, Sec. 5. (AB 3275) Effective January 1, 2025. Operative January 1, 2026, by its own provisions.