§ 2238.10. Definitions.
10 CA ADC § 2238.10Barclays Official California Code of Regulations
10 CCR § 2238.10
§ 2238.10. Definitions.
(1) “Average contracted rate” means the average of the contracted commercial rates paid by a health insurer for the same or similar health care services in the baseline year in the geographic region in which the service was provided, for services most frequently subject to Insurance Code section 10112.8. This rate is then adjusted to the date the service was rendered by using the inflation adjustment described in Insurance Code section 10112.82(a)(2)(B).
(6) “Same or similar services” means a health care service billed under the same service code, or a comparable code under a different procedural code system. The use of a different service code as a proxy for the service code ordinarily applicable to the actual service shall only be applied in a special or unique circumstance.
(b)(1) “Services most frequently subject to Section 10112.8” means, for the purpose of this article, the health care service codes, which, in aggregate, comprise the top 80 percent of the health insurer's statewide claims volume, determined by number of claims, when ranked in descending order beginning with the service codes with the highest number of claims, for all market segments for health care services subject to Insurance Code section 10112.8 for each of the following specialties:
(2) In addition to the health care services for the three specialties listed in subdivision (b)(1), “services most frequently subject to Section 10112.8” also includes all other services subject to Insurance Code section 10112.8, which, in aggregate, comprise the top 80 percent of the health insurer's statewide claims volume, determined by number of claims, when ranked in descending order beginning with the service codes with the highest number of claims, for all market segments for services other than those determined using subdivision (b)(1).
Credits
Note: Authority cited: Sections 10112.8 and 10112.82, Insurance Code. Reference: Sections 10112.8 and 10112.82, Insurance Code.
History
1. New article 5.5 (sections 2238.10-2238.12) and section filed 12-26-2018; operative 1-1-2019 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 52).
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 10, § 2238.10, 10 CA ADC § 2238.10
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