Request for Information Regarding Reasonable and Customary Emergency Claim Payment Methodology

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February13, 2015

Request for Information Regarding Reasonable and Customary Emergency Claim Payment Methodology as Defined in Rule 1300.71

Response Form for Capitated Providers[1]

Instructions: This Form is due to the Department of Managed Health Care (DMHC) via email to the Provider Solvency Unit at . Please email any questions to Michelle Yamanaka at .

Due Date: All responses are due on or before March 30, 2015.

Confidentiality: All responses will be considered confidential by the DMHC; this includes keeping the information confidential from the capitated provider’s contracting health plans.

Request for Information: Every capitated providershall submit responses to the questions below relating to the methodology the capitated provider uses to determine the reasonable and customary value of emergency services rendered by non-contracted providers. The responses shall include the methodology used for commercial claims and/or Medi-Cal claims.

DMHC Assigned RBO Identification Number:

Capitated Provider Name:

Principal Business Address:

Principal Officer Contact Information (Name, Title, Phone Number, Email Address):

Survey Responder Contact Information (Name, Title, Phone Number, Email Address):

Identify all Contracting Health Plans (Check all that apply):

____ Aetna Health of California

____ Anthem Blue Cross of California

____ Blue Shield of California

____ Care 1st Health Plan

____ Cigna Healthcare of California

____ Health Net of California

____ Inland Empire Health Plan

____ Local Initiative for Los Angeles County (L.A. Care Health Plan)

____ Molina Healthcare of California

____ Orange County Health Authority

____ UHC of California

____ Other: ______

If the attempt to negotiate each non-contracted claim within the statutory deadline is unsuccessful, is it the capitated provider’s policy to pay the non–contracted provider’s billed charge amount? Yes No

If “yes,” skip to Question 5. If “no,” continue to answer all questions.

Describe the capitated provider’s methodology for determining the reasonable and customary value of emergency facility/institutional-based services. This methodology includes, but is not limited to, the criteria outlined in Rule 1300.71(a)(3)(B). Include any changes to the capitated provider’s methodology in the last two years, as well as the date of such changes and the reason(s) for such changes. If the methodology involves the receipt of data from or consultation with a third party, describe the methodology employed by the third party.

Describe the capitated provider’s methodology for determining the reasonable and customary value of emergencyphysician/professional services, if the methodology differs from the methodology described in response to question 2, above. This methodology includes, but is not limited to, the criteria outlined in Rule 1300.71(a)(3)(B). Include any changes to the capitated provider’s methodology in the last two years, as well as the date of such changes and the reason(s) for such changes. If the methodology involves the receipt of data from or consultation with a third party, describe the methodology employed by the third party.

Describe how the capitated provider’s methodology considers the criteria outlined in Rule 1300.71(a)(3)(B). If the methodology involves the receipt of data from or consultation with a third party, describe how the methodology employed by the third party considers the criteria outlined in Rule 1300.71(a)(3)(B).

In light of the recent Children’s Hospital[2] court decision, does the capitated provider anticipate changing the methodologies described in response to questions 2 and 3? If you intend to change the methodologies, when do you anticipate doing so and describe in what ways the capitated provider anticipates making any changes.

List the capitated provider’s percentage of enrollment by county.

Please provide any additional information that the DMHC may find helpful and/or relevant as part of this study.

If a capitated provider or claims processing organization is unable to respond to any questions listed above, please state the reason(s) why,as well as what actions have been or will be taken to address these questions. The response should include the time frames needed to complete the necessary actions, and the expected date that a complete response will be provided to the DMHC.

[1] “Capitated Provider” includes medical groups and Independent Practice Associations that are classified as Risk Bearing Organizations.

[2]Children's Hosp. Cent. California v. Blue Cross of California, 226 Cal. App. 4th 1260, 1265, 172 Cal. Rptr. 3d 861, 865 (2014), review denied (Oct. 15, 2014).