SB 306 COMPLIANCE
Prior Authorization to Claims Matching Regulatory Compliance
THE CHALLENGE
Legacy Silos Cannot Meet New Mandates
The DMHC will issue reporting instructions by July 2026 that will define how plans must report on covered services, approval rates, and outcomes.
The legislation requires "authorization-native data" capable of supporting granular analysis at the CPT, HCPCS, or NDC level. Plans must demonstrate the lineage between a specific authorization request and the eventual care delivered (or denied).
The Delegation Dilemma
Under SB 306, the plan is accountable for delegate behavior. The disconnect between PA decisions made at the delegated entity and the claims adjudicated at the payer is amplified.
Service Code Drift and Granularity
SB 306 regulates Prior Authorization one code at a time; however, the code used during the PA request often differs from the code on the final claim.
Simple matching logic will view these as a mismatch leading to under-reporting of approved utilization and distorting the "value" metrics required by the state.
Temporal Mismatches
PA is prospective; claims are retrospective. The lag time for Durable Medical Equipment (DME), specialty drugs, or complex behavioral health episodes can span months.
Simplistic data matching will fail to link valid claims to their authorizations. Conversely, overly broad windows introduce "false positive" matches that inflate approval metrics−a red flag for DHMC auditors.
THE SOLUTION
PA to Claims Matching Service
Gaine introduces the PA to Claims Matching Service designed specifically for the SB 306 regulatory environment. This solution allows Knox-Keene plans to offload the complexity of data linkage to a sophisticated, auditable engine. This is not a dashboard or visualization tool; it is a mature Health Data Management Platform that accepts disparate data streams and returns a regulator-defensible linked data set.
SERVICE ARCHITECTURE
The solution is delivered as a service, minimizing the need for internal IT develop with the following capabilities:
Ingestion: The service ingests raw authorization files (from internal UM or delegates) and claims files (from adjudication systems).
Normalization: Data is normalized to a common schema, resolving inconsistent provider IDs (NPI vs. local IDs) and standardizing code sets.
Algorithmic Matching: The engine applies a sophisticated, multi-key matching logic that goes beyond simple Member ID joins.
Output: The system generates a linked record set, flagging matches, partial matches, and outliers with audit codes explaining why a match was made.
THE SOLUTION
PA to Claims Matching Service
Gaine introduces the PA to Claims Matching Service designed specifically for the SB 306 regulatory environment. This solution allows Knox-Keene plans to offload the complexity of data linkage to a sophisticated, auditable engine. This is not a dashboard or visualization tool; it is a mature Health Data Management Platform that accepts disparate data streams and returns a regulator-defensible linked data set.
SERVICE ARCHITECTURE
The solution is delivered as a service, minimizing the need for internal IT develop with the following capabilities:
Ingestion: The service ingests raw authorization files (from internal UM or delegates) and claims files (from adjudication systems).
Normalization: Data is normalized to a common schema, resolving inconsistent provider IDs (NPI vs. local IDs) and standardizing code sets.
Algorithmic Matching: The engine applies a sophisticated, multi-key matching logic that goes beyond simple Member ID joins.
Output: The system generates a linked record set, flagging matches, partial matches, and outliers with audit codes explaining why a match was made.
BENEFITS
Reduced Compliance Risk
The Gaine service provides traceability. Every match is accompanied by metadata explaining the logic used. Under audit, a plan can produce the lineage proving why a specific claim was linked to a specific authorization.
Speed to Implementation
SB 306 reporting deadlines are statutory. Gaine's pre-built logic and data governance platform allows plans to bypass risks and uncertainties of internal development. The service is designed to be called via API or secure batch transfer, integrating seamlessly with existing data warehouses.
Cost Avoidance
By using a shared service model, plans avoid the capital expenditure associated with building custom data lakes and matching algorithms. The solution allows smaller and mid-sized plans to achieve the same level of technical sophistication as national carriers without the associated price tag.
Delegated Oversight
The service illuminates the "black box" of delegated Utilization Management. By successfully linking delegate PAs to plan-paid claims, health plans gain visibility into delegate performance, enabling data-driven oversight and contract management.
THE CHALLENGE
Legacy Silos Cannot Meet New Mandates
The DMHC will issue reporting instructions by July 2026 that will define how plans must report on covered services, approval rates, and outcomes.
The legislation requires "authorization-native data" capable of supporting granular analysis at the CPT, HCPCS, or NDC level. Plans must demonstrate the lineage between a specific authorization request and the eventual care delivered (or denied).
