1. DMHC Updates ICE Annual Conference November 8, 2005
Rick Martin
Provider Oversight
California Department of Managed Health Care

2. SB 260 Implementation Revised regulations retroactive to July 1, 2005
Confidentiality
Web-based financial statement filing process
Filing timeliness - first quarterly filing due November 15
Grading Criteria
CAP process
External party responsibilities

3. Grading Criteria Claims timeliness IBNR methodology Positive TNE
Positive Working Capital
Cash Ratio
January 1,
July 1,
January 1,

4. Corrective Action Plans
Identifies the Grading Criteria the RBO failed to meet and the amount by which it failed to meet it
Identifies all Plans contracted with RBO
Describes specific actions the RBO will take to correct the deficiency
Time frame for completing the corrective action

5. AB 1455 Implementation Provider Complaint Unit – current statistics
Revisions to reporting formats
Reasonable & Customary reimbursement
Independent/Alternative Dispute Resolution Process

6. AB 1455 - Quarterly Reporting Changes
Reporting on five additional Emerging Claims Payment Deficiencies Failures effective October 1, 2005
(a)(8)(T)
(b)(1) – 90 days (contracted) & 180 days (non contracted)
(a)(8)(H)
(a)(8)(I)
Additional changes required effective October 1, 2006
Reporting Paid or Adjusted claims
Reporting Emergency Room Claims

7. AB 1455 – Annual Reporting Changes
Changes are the same as Quarterly requirements
Additional changes (effective October 1, 2005)
Disclosures of Emerging Claim Payment Deficiencies for Health Care Service Plans are in a ‘Yes’ or ‘No’ format
Disclosures of Emerging Claim Payment Deficiencies for payors are based on the Health Plan’s audit of the payor.
Provide Dispute Resolution changes (effective October 1, 2005)
Break out contracted and non-contracted claims payment/billing disputes
Separate the total number of claims payment/billing disputes by ‘Type’ of provider (I.e. professional, institutional, other).

8. New Regulations Regulations currently in formal rule making process
Prescription Drug Benefits and C0-Payments –
Conflict of Interest Code – 1000
Public Meeting and Hearing –
Regulations under development
Timely Access to Health Care Services (General Access) – , ,
Access to Language Assistance (including Waiting Room Notices Repeal) – , (f)
Centers of Excellence – TBD
Rural Critical Access –
Mental Health Parity –

9. Initiatives DMHC web-site redesign New licensing efiling system
Streamlining licensing review