Des Roches, et al. v. California Physicians’ Service, et al.

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA SAN JOSE DIVISION

Case No. 5:16-cv-2848 (LHK)

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Footnotes:

  • 1. The definition of Challenged Guidelines is contained in the Stipulation of Settlement, dated January 15, 2018. [Return to Text]

  • 2. Treatment Amount is defined in the Plan of Allocation, and that definition will control. However, it generally means the greater of (a) the amount that Defendants’ records reflect would have been used to calculate the benefit payments if a post-service claim had been approved, or (b) an amount calculated by multiplying the Class member’s Treatment Day(s) or Revised Treatment Day(s) number by the rate agreed to by Plaintiffs and Defendants based on Defendants’ claims and reimbursement data for the level of care for the year in which the denial occurred. [Return to Text]

  • 3. The definition of Treatment Day(s) is contained in the Plan of Allocation, and that definition will control. However, it generally means the days of treatment a Class member received, following a denial, at the level of care for which coverage was denied. The treatment must be connected to the denial, so there is a temporal component that requires the treatment to have been received within fourteen (14) days of the denial. [Return to Text]

  • 4. For example, the new documentation would not be used if it results in a lower Treatment Amount than the Treatment Amount based on information already contained in the Class Claims Data. [Return to Text]

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