CA Health & Safety Code Section 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.