1374.30
. (a) Commencing January 1, 2001, there is hereby
established in the department the Independent Medical Review System.
(b) For the purposes of this chapter, "disputed health care
service" means any health care service eligible for coverage and
payment under a health care service plan contract that has been
denied, modified, or delayed by a decision of the plan, or by one of
its contracting providers, in whole or in part due to a finding that
the service is not medically necessary. A decision regarding a
disputed health care service relates to the practice of medicine and
is not a coverage decision. A disputed health care service does not
include services provided by a specialized health care service plan,
except to the extent that the service (1) involves the practice of
medicine, or (2) is provided pursuant to a contract with a health
care service plan that covers hospital, medical, or surgical
benefits. If a plan, or one of its contracting providers, issues a
decision denying, modifying, or delaying health care services, based
in whole or in part on a finding that the proposed health care
services are not a covered benefit under the contract that applies to
the enrollee, the statement of decision shall clearly specify the
provision in the contract that excludes that coverage.
(c) For the purposes of this chapter, "coverage decision" means
the approval or denial of health care services by a plan, or by one
of its contracting entities, substantially based on a finding that
the provision of a particular service is included or excluded as a
covered benefit under the terms and conditions of the health care
service plan contract. A "coverage decision" does not encompass a
plan or contracting provider decision regarding a disputed health
care service.
(d) (1) All enrollee grievances involving a disputed health care
service are eligible for review under the Independent Medical Review
System if the requirements of this article are met. If the department
finds that an enrollee grievance involving a disputed health care
service does not meet the requirements of this article for review
under the Independent Medical Review System, the enrollee request for
review shall be treated as a request for the department to review
the grievance pursuant to subdivision (b) of Section 1368. All other
enrollee grievances, including grievances involving coverage
decisions, remain eligible for review by the department pursuant to
subdivision (b) of Section 1368.
(2) In any case in which an enrollee or provider asserts that a
decision to deny, modify, or delay health care services was based, in
whole or in part, on consideration of medical necessity, the
department shall have the final authority to determine whether the
grievance is more properly resolved pursuant to an independent
medical review as provided under this article or pursuant to
subdivision (b) of Section 1368.
(3) The department shall be the final arbiter when there is a
question as to whether an enrollee grievance is a disputed health
care service or a coverage decision. The department shall establish a
process to complete an initial screening of an enrollee grievance.
If there appears to be any medical necessity issue, the grievance
shall be resolved pursuant to an independent medical review as
provided under this article or pursuant to subdivision (b) of Section
1368.
(e) Every health care service plan contract that is issued,
amended, renewed, or delivered in this state on or after January 1,
2000, shall provide an enrollee with the opportunity to seek an
independent medical review whenever health care services have been
denied, modified, or delayed by the plan, or by one of its
contracting providers, if the decision was based in whole or in part
on a finding that the proposed health care services are not medically
necessary. For purposes of this article, an enrollee may designate
an agent to act on his or her behalf, as described in paragraph (2)
of subdivision (b) of Section 1368. The provider may join with or
otherwise assist the enrollee in seeking an independent medical
review, and may advocate on behalf of the enrollee.
(f) Medi-Cal beneficiaries enrolled in a health care service plan
shall not be excluded from participation. Medicare beneficiaries
enrolled in a health care service plan shall not be excluded unless
expressly preempted by federal law. Reviews of cases for Medi-Cal
enrollees shall be conducted in accordance with statutes and
regulations for the Medi-Cal program.
(g) The department may seek to integrate the quality of care and
consumer protection provisions, including remedies, of the
Independent Medical Review System with related dispute resolution
procedures of other health care agency programs, including the
Medicare and Medi-Cal programs, in a way that minimizes the potential
for duplication, conflict, and added costs. Nothing in this
subdivision shall be construed to limit any rights conferred upon
enrollees under this chapter.
(h) The independent medical review process authorized by this
article is in addition to any other procedures or remedies that may
be available.
(i) Every health care service plan shall prominently display in
every plan member handbook or relevant informational brochure, in
every plan contract, on enrollee evidence of coverage forms, on
copies of plan procedures for resolving grievances, on letters of
denials issued by either the plan or its contracting organization, on
the grievance forms required under Section 1368, and on all written
responses to grievances, information concerning the right of an
enrollee to request an independent medical review in cases where the
enrollee believes that health care services have been improperly
denied, modified, or delayed by the plan, or by one of its
contracting providers.
(j) An enrollee may apply to the department for an independent
medical review when all of the following conditions are met:
(1) (A) The enrollee's provider has recommended a health care
service as medically necessary, or
(B) The enrollee has received urgent care or emergency services
that a provider determined was medically necessary, or
(C) The enrollee, in the absence of a provider recommendation
under subparagraph (A) or the receipt of urgent care or emergency
services by a provider under subparagraph (B), has been seen by an
in-plan provider for the diagnosis or treatment of the medical
condition for which the enrollee seeks independent review. The plan
shall expedite access to an in-plan provider upon request of an
enrollee. The in-plan provider need not recommend the disputed health
care service as a condition for the enrollee to be eligible for an
independent review.
For purposes of this article, the enrollee's provider may be an
out-of-plan provider. However, the plan shall have no liability for
payment of services provided by an out-of-plan provider, except as
provided pursuant to subdivision (c) of Section 1374.34.
(2) The disputed health care service has been denied, modified, or
delayed by the plan, or by one of its contracting providers, based
in whole or in part on a decision that the health care service is not
medically necessary.
(3) The enrollee has filed a grievance with the plan or its
contracting provider pursuant to Section 1368, and the disputed
decision is upheld or the grievance remains unresolved after 30 days.
The enrollee shall not be required to participate in the plan's
grievance process for more than 30 days. In the case of a grievance
that requires expedited review pursuant to Section 1368.01, the
enrollee shall not be required to participate in the plan's grievance
process for more than three days.
(k) An enrollee may apply to the department for an independent
medical review of a decision to deny, modify, or delay health care
services, based in whole or in part on a finding that the disputed
health care services are not medically necessary, within six months
of any of the qualifying periods or events under subdivision (j). The
director may extend the application deadline beyond six months if
the circumstances of a case warrant the extension.
(l) The enrollee shall pay no application or processing fees of
any kind.
(m) As part of its notification to the enrollee regarding a
disposition of the enrollee's grievance that denies, modifies, or
delays health care services, the plan shall provide the enrollee with
a one- or two-page application form approved by the department, and
an addressed envelope, which the enrollee may return to initiate an
independent medical review. The plan shall include on the form any
information required by the department to facilitate the completion
of the independent medical review, such as the enrollee's diagnosis
or condition, the nature of the disputed health care service sought
by the enrollee, a means to identify the enrollee's case, and any
other material information. The form shall also include the
following:
(1) Notice that a decision not to participate in the independent
medical review process may cause the enrollee to forfeit any
statutory right to pursue legal action against the plan regarding the
disputed health care service.
(2) A statement indicating the enrollee's consent to obtain any
necessary medical records from the plan, any of its contracting
providers, and any out-of-plan provider the enrollee may have
consulted on the matter, to be signed by the enrollee.
(3) Notice of the enrollee's right to provide information or
documentation, either directly or through the enrollee's provider,
regarding any of the following:
(A) A provider recommendation indicating that the disputed health
care service is medically necessary for the enrollee's medical
condition.
(B) Medical information or justification that a disputed health
care service, on an urgent care or emergency basis, was medically
necessary for the enrollee's medical condition.
(C) Reasonable information supporting the enrollee's position that
the disputed health care service is or was medically necessary for
the enrollee's medical condition, including all information provided
to the enrollee by the plan or any of its contracting providers,
still in the possession of the enrollee, concerning a plan or
provider decision regarding disputed health care services, and a copy
of any materials the enrollee submitted to the plan, still in the
possession of the enrollee, in support of the grievance, as well as
any additional material that the enrollee believes is relevant.
(4) A section designed to collect information on the enrollee's
ethnicity, race, and primary language spoken that includes both of
the following:
(A) A statement of intent indicating that the information is used
for statistics only, in order to ensure that all enrollees get the
best care possible.
(B) A statement indicating that providing this information is
optional and will not affect the independent medical review process
in any way.
(n) Upon notice from the department that the health care service
plan's enrollee has applied for an independent medical review, the
plan or its contracting providers shall provide to the independent
medical review organization designated by the department a copy of
all of the following documents within three business days of the plan'
s receipt of the department's notice of a request by an enrollee for
an independent review:
(1) (A) A copy of all of the enrollee's medical records in the
possession of the plan or its contracting providers relevant to each
of the following:
(i) The enrollee's medical condition.
(ii) The health care services being provided by the plan and its
contracting providers for the condition.
(iii) The disputed health care services requested by the enrollee
for the condition.
(B) Any newly developed or discovered relevant medical records in
the possession of the plan or its contracting providers after the
initial documents are provided to the independent medical review
organization shall be forwarded immediately to the independent
medical review organization. The plan shall concurrently provide a
copy of medical records required by this subparagraph to the enrollee
or the enrollee's provider, if authorized by the enrollee, unless
the offer of medical records is declined or otherwise prohibited by
law. The confidentiality of all medical record information shall be
maintained pursuant to applicable state and federal laws.
(2) A copy of all information provided to the enrollee by the plan
and any of its contracting providers concerning plan and provider
decisions regarding the enrollee's condition and care, and a copy of
any materials the enrollee or the enrollee's provider submitted to
the plan and to the plan's contracting providers in support of the
enrollee's request for disputed health care services. This
documentation shall include the written response to the enrollee's
grievance, required by paragraph (4) of subdivision (a) of Section
1368. The confidentiality of any enrollee medical information shall
be maintained pursuant to applicable state and federal laws.
(3) A copy of any other relevant documents or information used by
the plan or its contracting providers in determining whether disputed
health care services should have been provided, and any statements
by the plan and its contracting providers explaining the reasons for
the decision to deny, modify, or delay disputed health care services
on the basis of medical necessity. The plan shall concurrently
provide a copy of documents required by this paragraph, except for
any information found by the director to be legally privileged
information, to the enrollee and the enrollee's provider. The
department and the independent medical review organization shall
maintain the confidentiality of any information found by the director
to be the proprietary information of the plan.
(o) This section shall become operative on July 1, 2015.