(a) The plan's financial liability to the provider, if any, shall not exceed the lower of the following rates applicable at the time the services were rendered by the provider:
- (1) The usual charges made to the general public by the provider.
- (2) The fee-for-service rates for similar services under the Medi-Cal program. Upon determination of the plan's liability, if no final rate has been established for a provider for the period and type of services in question, then the applicable interim rate shall be used for final determination of plan liability.
- (b) The amount demanded shall be presumed to be correct, and the provider shall be entitled to the full amount demanded in its claim should it prevail, unless the plan files a Notice of Defense, pursuant to Section 53632, which places the amount of the provider's demand for payment in issue.
Note: Authority cited: Sections 14312 and 14454, Welfare and Institutions Code. Reference: Section 14454, Welfare and Institutions Code.
History
1. Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No. 36).