Section 1374.69 Of Article 5.6. Point-of-service Health Care Service Plan Contracts From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.6.
1374.69
. At least 20 business days prior to offering a
point-of-service plan contract, a health care service plan shall file
a notice of material modification in accordance with Section 1352.
The notice of material modification shall include, but not be limited
to, provisions specifying how the health care service plan shall
accomplish all of the following:
(a) Design the benefit levels and conditions of coverage for
in-network coverage and services and out-of-network point-of-service
utilization.
(b) Provide or arrange for the provision of adequate systems to do
all of the following:
(1) Process and pay claims for all out-of-network coverage and
services.
(2) Generate accurate financial and utilization data and reports
on a timely basis, so that it and any authorized regulatory agency
can evaluate the health care service plan's experience with
point-of-service plan contracts and monitor compliance with
point-of-service plan contract projections established by the health
care service plan and regulatory requirements.
(3) Track and monitor the quality of health care obtained
out-of-network by plan enrollees to the extent reasonable and
possible.
(4) Respond promptly to enrollee grievances and complaints,
written or oral, including those regarding services obtained
out-of-network.
(5) Meet the requirements for a point-of-service plan contract set
forth in this section and any additional requirements that may be
required by the director.
(c) Comply initially and on an ongoing basis with the requirements
of this article.
(d) This section shall become operative July 1, 1995.