Second Reviews for Incorrect Payment per a Pre-Negotiated 5307.11 Contract

When a claims administrator remits incorrect payment per a pre-negotiated 5307.11 contract, we strongly encourage you to file a request for Second Review.

Frequently Asked Question

Q: Which specific Code may I cite in my Second Review for an incorrect payment per a pre-negotiated 5307.11 contract?

A: For Physician Services, if a claims administrator disputes a 5307.11 contracted reimbursement as outside the fee schedule, the request for Second Review should cite CCR § 9789.12.1.

Explanation 

Per CCR § 9789.12.1 Official Medical Fee Schedule for Physician and Non-Physician Practitioner Services – For Services Rendered On or After January 1, 2014: “The Physician Fee Schedule shall not govern fees for services covered by a contract setting such fees as permitted by Labor Code section 5307.11.”

For services other than Physician Services, if a claims administrator disputes a 5307.11 contracted reimbursement as outside the fee schedule, the request for Second Review should cite the the following Labor Codes:

California Labor Code Section 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.

California Labor Code Section 5307.1(h) This section does not prohibit an employer or insurer from contracting with a medical provider for reimbursement rates different from those prescribed in the official medical fee schedule.

Additional Information

California Labor Code § 5307.11

California Labor Code § 5307.1(h)

California Code of Regulations § 9789.12.1

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