California law states that a Quarterly Claims Settlement Practices Report must be submitted for each licensed health care service plan. Health care service plans report claim information if the plan or any of its capitated providers* has failed to reimburse at least 95% of complete claims with correct payment including interest and penalties due, that became payable during the reporting period. The following charts summarize the deficiencies reported by the health plans for the most recent four quarters. According to regulations, the annual period for Claims Payment and Dispute Resolution reporting purposes is the last calendar quarter of the year preceding the reporting year, and the first three calendar quarters for the reporting year.
The individual reports are submitted by health plans and include the non-compliant areas reported by the health plan and/or any of its contracted capitated providers.
*Capitated providers include all risk-bearing organizations and any other medical provider that accepts capitation and pays claims.
How to Use This Report
The automated Quarterly Claims Settlement Practices Report Summary mirrors the current report’s format; recent enhancements include viewing the Quarterly Claim Settlement Reports that are submitted to the Department. When the mouse pointer is moved over a total in the report, the list of non-complaint health plans and/or capitated providers will be displayed.
Once the health plan or capitated provider is selected, the report filed with the Department will appear. Please note the data below summarizes self-reported information submitted by health plans. The Department is working with the health plans and capitated providers to ensure correct reporting and will update this data if a health plan submits a revision. Since the reported numbers are collected with real-time information, the report may change as these revisions are made.
View the report