Section 1371.1 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1371.1
. (a) Whenever a health care service plan, including a
specialized health care service plan, determines that in reimbursing
a claim for provider services an institutional or professional
provider has been overpaid, and then notifies the provider in writing
through a separate notice identifying the overpayment and the amount
of the overpayment, the provider shall reimburse the health care
service plan within 30 working days of receipt by the provider of the
notice of overpayment unless the overpayment or portion thereof is
contested by the provider in which case the health care service plan
shall be notified, in writing, within 30 working days. The notice
that an overpayment is being contested shall identify the portion of
the overpayment that is contested and the specific reasons for
contesting the overpayment.
If the provider does not make reimbursement for an uncontested
overpayment within 30 working days after receipt, interest shall
accrue at the rate of 10 percent per annum beginning with the first
calendar day after the 30-working-day period.
(b) (1) This subdivision shall only apply to a health care service
plan contract covering dental services or a specialized health care
service plan contract covering dental services pursuant to this
chapter.
(2) The health care service plan's notice of overpayment shall
inform the provider how to access the plan's dispute resolution
mechanism offered pursuant to subdivision (h) of Section 1367. The
notice shall include the name and address to which the dispute should
be submitted and a statement that Section 1371.1 of the Health and
Safety Code requires a provider to reimburse the plan for an
overpayment within 30 working days of receipt by the provider of the
notice of overpayment unless the provider contests the overpayment
within 30 working days. The notice shall also include information
clearly identifying the claim, the name of the patient, the date of
service, and a clear explanation of the basis upon which the plan or
the plan's capitated provider believes the amount paid on the claim
was in excess of the amount due, including interest and penalties on
the claim. The notice shall also include a statement that if the
provider does not make reimbursement of an uncontested overpayment
within 30 working days after receipt of the notice, interest shall
accrue at a rate of 10 percent per annum.