AB 2499: Health care coverage: claims payments.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.

Existing law requires a health care service plan or health insurer to reimburse a complete claim or a portion thereof within 30 calendar days after receipt of the claim, or, if a claim or portion thereof does not meet the criteria for a complete claim or the criteria for coverage under the plan or insurance contract, to notify the claimant in writing that the claim or portion thereof is contested or denied as soon as practicable, but no later than 30 calendar days after receipt of the claim by the plan or insurer.

This bill would would, commencing May 26, 2028, require a plan or insurer to accept electronic medical records and supporting documentation necessary to process a claim through a standard electronic submission method, as defined, and would prohibit a plan or insurer from denying, pending, or delaying a claim solely because the plans or insurers systems are unable to accept documentation that otherwise meets the plans or insurers requirements. The bill would specify that if a state or federal standard is adopted that is specific to file size, number, or other capacity requirements for claims-related supporting documentation submissions, that standard would apply.

Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.