Section 1363.5 Of Article 4. Solicitation And Enrollment From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 4.
1363.5
. (a) A plan shall disclose or provide for the disclosure to
the director and to network providers the process the plan, its
contracting provider groups, or any entity with which the plan
contracts for services that include utilization review or utilization
management functions, uses to authorize, modify, or deny health care
services under the benefits provided by the plan, including coverage
for subacute care, transitional inpatient care, or care provided in
skilled nursing facilities. A plan shall also disclose those
processes to enrollees or persons designated by an enrollee, or to
any other person or organization, upon request. The disclosure to the
director shall include the policies, procedures, and the description
of the process that are filed with the director pursuant to
subdivision (b) of Section 1367.01.
(b) The criteria or guidelines used by plans, or any entities with
which plans contract for services that include utilization review or
utilization management functions, to determine whether to authorize,
modify, or deny health care services shall:
(1) Be developed with involvement from actively practicing health
care providers.
(2) Be consistent with sound clinical principles and processes.
(3) Be evaluated, and updated if necessary, at least annually.
(4) If used as the basis of a decision to modify, delay, or deny
services in a specified case under review, be disclosed to the
provider and the enrollee in that specified case.
(5) Be available to the public upon request. A plan shall only be
required to disclose the criteria or guidelines for the specific
procedures or conditions requested. A plan may charge reasonable fees
to cover administrative expenses related to disclosing criteria or
guidelines pursuant to this paragraph, limited to copying and postage
costs. The plan may also make the criteria or guidelines available
through electronic communication means.
(c) The disclosure required by paragraph (5) of subdivision (b)
shall be accompanied by the following notice: "The materials provided
to you are guidelines used by this plan to authorize, modify, or
deny care for persons with similar illnesses or conditions. Specific
care and treatment may vary depending on individual need and the
benefits covered under your contract."