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    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyPHC California ASA Filing Policy Update | OpenPaye…
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    CurrentPHC CaliforniaPolicy CO 19.1

    PHC-CA DMHC Administrative Services Agreement Filings

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    Governs PHC California’s filing, oversight, and annual reconciliation of administrative services agreements involving delegated or assumed Knox-Keene Act-regulated or required nonclinical functions.

    Policy Summary
    PayerPHC California
    PolicyPHC-CA DMHC Administrative Services Agreement Filings
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMay 1, 2024
    Next Review DateN/A
    Key ActionFile every covered administrative services agreement or amendment with DMHC.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2DMHC filing pathways
    30 daysAmendment Filing deadline
    N-1/N-3ASA exhibit types
    N-6Compensation exhibit
    AnnualASA reconciliation frequency

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    6Oversight components

    Filing Classification and Required Materials

    Determine filing type

    Classify the ASA filing based on operational materiality and the location of records.

    Notice of Material Modification

    • The ASA or amendment has a material effect on Health Plan operations.
    • Records of, or resulting from, the ASA are maintained or moved outside California.

    Amendment Filing

    • The ASA does not have a material effect on Health Plan operations.
    • Records of, or resulting from, the ASA are maintained in California.

    Required ASA exhibits and oversight materials

    Include exhibits and oversight materials appropriate to the ASA and the delegated functions.

    Exhibit N-1

    • The ASA delegates or assumes a Knox-Keene Act-regulated nonclinical or health care function other than claims processing.
    • Claims processing is one of several Knox-Keene Act-regulated functions delegated through the ASA.

    Exhibit N-3

    • The ASA delegates or assumes only claims processing functions.

    Exhibit N-6

    • The filing includes ASA compensation provisions.

    Exhibit N-2

    • The filing includes monitoring and performance-resolution arrangements for the specific ASA.

    Filing and Reconciliation Responsibilities

    Documentation Required

    File Covered ASAs

    File every administrative, management, consulting, or other covered contract or amendment involving a function the Plan delegates or assumes that is regulated or required under the Knox-Keene Act.

    • Covered arrangements include administrative, management, and consulting contracts and other contracts or amendments involving nonclinical/health functions.
    • File the arrangement with the Department of Managed Health Care (DMHC) for review and approval.
    Prior Authorization

    Use a Notice of Material Modification

    Submit a Notice of Material Modification to the Plan’s license when the ASA or amendment materially affects Plan operations, or when records of or resulting from the ASA are maintained or moved outside California. Submit as early as possible before the ASA takes effect; an ASA filed as a Notice may not take effect until DMHC approval.

    Policy Summary
    PayerPHC California
    PolicyPHC-CA DMHC Administrative Services Agreement Filings
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMay 1, 2024
    Next Review DateN/A
    Key ActionFile every covered administrative services agreement or amendment with DMHC.
    SourceLink
    On This Page
    Filing Classification and Required MaterialsFiling and Reconciliation Responsibilities

    Exhibit N-5

    • The filing includes new or revised ASA monitoring policies and procedures.

    ASA monitoring policy components

    • Monitoring policies and procedures are submitted for ASA oversight.
  1. Material operational effect: file a Notice under Rule 1300.52.4(d).
  2. Records maintained or moved outside California: file under Rule 1300.81.
  3. File before the ASA takes effect whenever possible.
    4. Billing Rule

    Use an Amendment Filing

    Submit an Amendment Filing when the ASA does not materially affect Plan operations and the records of, and resulting from, the ASA are maintained in California. File changes to previously provided information, including new ASAs, amendments, terminations, and changes to policies and procedures governing ASA oversight; template or boilerplate ASAs may also be submitted as Amendment Filings.

    • The filing must comply with Section 1352 and Rules 1300.52 and 1300.52.4(a) or (b).
    • Include new ASAs, amendments, terminations, and oversight-policy or procedure changes.
    Prior Authorization

    Meet the Amendment Filing Deadline

    File the Amendment Filing before the ASA takes effect whenever possible. If it was not filed beforehand, submit it no later than thirty (30) days after the ASA goes into effect.

    • Preferred deadline: before the effective date.
    • Outside deadline when filed after effectiveness: within 30 days after the effective date.
    • Do not delay a post-effective filing beyond the 30-day limit.

    Unsupported block type: documentation

    Documentation Required

    Reconcile ASA Filings Annually

    The Compliance Officer or designee must annually reconcile all ASAs to identify material modifications and amendments that require filing with DMHC. Track the reconciliation in the Business Intelligence (BI) Portal Report Manager.

    • Review all covered ASAs each year.
    • Confirm material modifications and amendments are properly filed.
    • Document tracking in the BI Portal Report Manager.