I. Purpose. Departments(s) and Committee(s) Affected:

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1 Page 1 of 7 I. Purpose A. To establish ValueOptions of California Inc. ( VOC or the Plan ) policies and procedures for receipt, review, and completing the accurate and timely adjudication of claims for emergency care and services and urgent care services. This policy and procedure is utilized for the Plan s Knox-Keene approved Mental Health/Substance Abuse (MHSA) benefit plans. This policy does not apply to the Employee Assistance Program ( EAP ) as emergency services and care is not a covered benefit under EAP benefit plans. B. To ensure compliance with the requirements of Sections , , , and of the California Knox-Keene Health Care Service Plan Act of 1975 as amended, Section of the California Health and Safety Code, and Rules , , and of Title 28 of the California Code of Regulations. These regulatory requirements are enforced by the Department of Managed Health Care ( DMHC ). C. Except where the guidelines in this policy specify otherwise, claims for emergency care and services are also subject to the same guidelines for review and processing of claims not involving emergency care and services, see policy # CL002P (Timely Claims Processing). Providers may also submit disputes related to claims involving emergency services and such disputes must be handled according to the Plan policy # CSC204P. II. Departments(s) and Committee(s) Affected: A. Claims Department B. Claims Customer Service C. Finance Department D. Provider Dispute staff E. QM Committee III. Policy

2 Page 2 of 7 A. The Plan will reimburse each complete claim, or portion thereof, whether in state or out of state, as soon as practical, but no later than 30 working days after receipt of the complete claim by the Plan. B. The Plan may contest or deny a claim, or portion thereof, by notifying the claimant, in writing, that the claim is contested or denied, within 30 working days after receipt of the claim by the Plan. 1. The notice that a claim, or portion thereof, is contested will identify the portion of the claim that is contested, by revenue code, and the specific information needed from the provider to reconsider the claim. 2. The notice that a claim, or portion thereof, is denied will identify the portion of the claim that is denied, by revenue code, and the specific reasons for the denial. The Plan may delay payment of an uncontested portion of a complete claim for reconsideration of a contested portion of that claim if the Plan pays those charges specified in section C below. C. If a complete claim or portion of the claim, that is neither contested nor denied, is not reimbursed by delivery to the claimant's address of record within 30 working days after receipt, the Plan must pay the greater of fifteen dollars ($15) per year or interest at the rate of 15 percent per annum beginning with the first calendar day after the 30 working day period. The Plan must automatically (see definition in CL008P) include the fifteen dollars ($15) per year or interest due in the payment made to the claimant, without requiring a request from the claimant. Refer to policy # CL008P Commercial Interest Payment for the instructions on how to calculate interest amounts. D. If a claim or portion thereof is contested on the basis that the Plan has not received information reasonably necessary to determine payer liability for the claim or portion thereof, then the Plan has 30 working days after receipt of this additional information to complete reconsideration of the claim. If a claim, or portion thereof, undergoing reconsideration is not reimbursed by delivery to the claimant's address of record within 30 working days after receipt of the additional information, the Plan shall pay the greater of fifteen dollars ($15) per year or interest at the rate of 15 percent per annum beginning with the first calendar day

3 Page 3 of 7 after the 30 working day period. The Plan will automatically include the fifteen dollars ($15) per year or interest due in the payment made to the claimant, without requiring a request from the claimant. Refer to policy #CL008P Commercial Interest Payment for the instructions on how to calculate interest amounts. E. The timeframe and interest requirements in this policy do not apply to claims when there is evidence of fraud and misrepresentation, to eligibility determinations, or in instances where the Plan has not been granted reasonable access to information under the provider's control. In one these exception cases, the Plan will send a written notice sent to the provider within 30 working days of receipt of the claim identifying which of these exceptions applies to a claim. F. The Plan will not delay payment on a claim from a physician or other provider to await the submission of a claim from a hospital or other provider, without citing specific rationale as to why the delay was necessary. The Plan will provide a monthly update regarding the status of such a claim and the Plan's actions to resolve the claim, to the provider that submitted the claim. G. It is the Plan s policy not to require prior authorization for emergency or out of area urgent care. However, the claim system has been designed to check for authorization prior to adjudication for those times when a contracted provider may have requested approval prior to sending a member for services, or an authorization has been entered prior to receipt of the claim. Claims for out of area and in area urgent care services are to be reviewed following the same guidelines as emergency room claims. (See policy CL002P Timely Claims Processing and Policy CSC204P Provider Dispute Resolution Mechanism for more information related to claims and dispute requirements.) IV. Definitions A. Complete claim means a claim or portion thereof, if separable, including attachments and supplemental information or documentation, which provides: reasonably relevant information and information necessary to determine payer

4 Page 4 of 7 liability as defined in the Definitions section of policy # CL002P (Timely Claims Processing), and: 1. For emergency services and care provider claims as defined by Section (j) of the Knox-Keene Act (Refer to the definitions in sections B and C below for these cited definitions): a. The information specified in Section (c) of the Health and Safety Code; and b. Any state-designated data requirements included in statutes or regulations. 2. Section (c) specifies the following information: A claim, or portion of thereof, is reasonably contested if VOC has not received the completed claim as described below. a. A paper claim from an institutional provider shall be deemed complete upon submission of a legible emergency department report and a completed UB 92 or other format adopted by the National Uniform Billing Committee, and reasonable relevant information requested by the Plan within 30 working days of receipt of the claim. b. An electronic claim from an institutional provider shall be deemed complete upon submission of an electronic equivalent to the UB 92 or other format adopted by the National Uniform Billing Committee, and reasonable relevant information requested by the Plan within 30 working days of receipt of the claim. i. However, if the Plan requests a copy of the emergency department report within the 30 working days after receipt of the electronic claim from the institutional provider, the Plan may also request additional reasonable relevant information within 30 working days of receipt of the emergency department report, at which time the claim must be considered complete.

5 Page 5 of 7 c. A claim from a professional provider shall be deemed complete upon submission of a completed HCFA 1500 or its electronic equivalent or other format adopted by the National Uniform Billing Committee, and reasonable relevant information requested by the Plan within 30 working days of receipt of the claim. i. The provider shall provide the Plan reasonable relevant information within 10 working days of receipt of a written request that is clear and specific regarding the information sought. ii. If, as a result of reviewing the reasonable relevant information, the Plan requires further information, the Plan has an additional 15 working days after receipt of the reasonable relevant information to request the further information at which time the claim is deemed complete. B. Emergency Medical Or Behavioral Condition: A medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (1) placing the health of the person affected with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of the persons or others in serious jeopardy; or (2) serious impairment to such person s bodily functions; or (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person. C. Emergency Services and Care: Means those covered services provided for screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. 1. Medically Necessary ambulance and ambulance transport services provided through the 911 emergency response system also qualify as

6 Page 6 of 7 emergency services and care and claims for such ambulance services must be processed according to the guidelines in this policy. (See policy CL002P Timely Claims Processing for additional definitions) V. Procedure A. Claims for emergency services or urgent care are researched and adjudicated in the same manner as claims for routine services as described in policy CL002P. The steps below describe some of the specific review circumstances applicable to emergency services and urgent care claims. B. Claims received for emergency or urgent care services are reviewed for prior existence of an authorization. An authorization would include: 1. A contracted provider refers the member, 2. A contracted provider s answering service refers the member to an Emergency Room or Urgent Care, 3. Any time services are received as a result of VOC staff directing members to call 911 or go to an emergency room. C. A referral made by any of the above sources will result in payment. D. If no authorization is in the system: 1. The processor will look at the admitting diagnosis and compare it to the list of automatically approved diagnosis codes. If the diagnosis is on the list, the processor will continue with the payment process. 2. If the diagnosis is not on the auto-pay list, the processor is to determine by means of a call, if a contracted physician or other source (see section B above) referred the member. 3. If either of the above is met, proceed with payment process.

7 Page 7 of 7 E. If the admitting diagnosis is not on the list for auto pay, the claim will be routed to the Medical Director for review. F. The Medical Director will review the claim and any supporting documentation to make a determination. If the services rendered, or admitting diagnosis or symptoms as reported by the patient meet the definitions in section IV.B and C above, the Medical Director will approve the claim, document the decision and return the claim to the processor, who will continue to adjudicate the claim following the process in CL002P. G. If the Medical Director denies the claim based on medical necessity reasons, the denial reason will be documented and the claim returned to the processor. The processor will then complete the claim adjudication process and a denial will be issued on a Provider Summary Voucher and Explanation of Benefits statement. A claim for emergency services may not be denied with a reason stating there was no prior authorization.