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Effective January 1, 2004, health plans, capitated providers, and their claims processing
organizations were required to be in full compliance with California regulations
promulgated under AB 1455/SB 1177...2000. These regulations set standards for claims
processing and dispute resolution mechanisms to facilitate the prompt and efficient
submission, processing and payment of claims and fast, fair and cost-effective dispute
resolution. The Ventura County Health Care Plan (VCHCP) intensely reviewed the regulations,
and as necessary, modified and enhanced its claim, provider network, contracts,
reporting and provider appeal functions to meet regulatory standards. Using this
Web site as a critical mechanism for communicating with providers, VCHCP will keep
providers who serve our enrollees more fully informed of the health plan's claims
settlement practices and policies.
Disclosures for Contracting Providers
The following information is provided in accordance with 28 CCR 1300.71(o) (2),
regarding disclosure of detailed payment policies and rules and nonstandard coding
methodologies used to adjudicate claims. VCHCP, in its sole discretion, employs
the procedures set out in the following descriptions as part of its claims review,
as indicated, of hospital and professional fee for service claims. Providers may
only look to VCHCP, or if subcontracted to a VCHCP capitated provider, to that provider,
for payment and not to enrollees (except for required copayments) or to any technical
services vendor VCHCP may use from time to time to assist in its review of claims.
The information contained in this section applies to providers who have signed an
agreement with VCHCP to participate as a network provider. These guidelines describe
general policies and procedures. Please refer to your agreement for specific contractual
information.
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