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Section 1371.36 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1371.36
. (a) A health care service plan shall not deny payment of a
claim on the basis that the plan, medical group, independent
practice association, or other contracting entity did not provide
authorization for health care services that were provided in a
licensed acute care hospital and that were related to services that
were previously authorized, if all of the following conditions are
met:
(1) It was medically necessary to provide the services at the time.
(2) The services were provided after the plan's normal business hours.
(3) The plan does not maintain a system that provides for the availability of a plan representative or an alternative means of contact through an electronic system, including voicemail or electronic mail, whereby the plan can respond to a request for authorization within 30 minutes of the time that a request was made.
(b) This section shall not apply to investigational or experimental therapies, or other noncovered services.
(1) It was medically necessary to provide the services at the time.
(2) The services were provided after the plan's normal business hours.
(3) The plan does not maintain a system that provides for the availability of a plan representative or an alternative means of contact through an electronic system, including voicemail or electronic mail, whereby the plan can respond to a request for authorization within 30 minutes of the time that a request was made.
(b) This section shall not apply to investigational or experimental therapies, or other noncovered services.
