Payer contract review for California medical practices

Identify the plan and the entity responsible for payment

For California practices, first establish the payer product, any delegated contracting or payment entity, and the regulator. DMHC’s provider resources apply to its regulated plans; do not treat a provider dispute process as a universal rule for every insurance agreement.

• Does your agreement place contracting, authorization and payment with the same entity?

What a California contract review should establish

Identify executed agreements, later amendments, fee schedules and notice deadlines. Commercial contracts more than five years old are eligible for renegotiation screening; the agreement’s renewal and amendment provisions still govern the process. Higher rates are not guaranteed.

• Which plan products and providers does the agreement cover?
• Which high-volume codes have matched comparison evidence, and which remain unbenchmarked?
• What notice or amendment steps are required before contacting the payer?

National references are not verified local rates

NPAG’s online tools currently use national commercial reference figures for supported codes. They do not show verified state-specific or payer-product-specific offers. A practice-specific comparison must match code, date, locality, network and service setting.

CMS geography is useful when an agreement references Medicare. It is not proof of commercial negotiating leverage. State provider guidance is a starting point for applicable processes, not legal advice or a promise of a new fee schedule.