1374.33
. (a) Upon receipt of information and documents related to a
case, the medical professional reviewer or reviewers selected to
conduct the review by the independent medical review organization
shall promptly review all pertinent medical records of the enrollee,
provider reports, as well as any other information submitted to the
organization as authorized by the department or requested from any of
the parties to the dispute by the reviewers. If reviewers request
information from any of the parties, a copy of the request and the
response shall be provided to all of the parties. The reviewer or
reviewers shall also review relevant information related to the
criteria set forth in subdivision (b).
(b) Following its review, the reviewer or reviewers shall
determine whether the disputed health care service was medically
necessary based on the specific medical needs of the enrollee and any
of the following:
(1) Peer-reviewed scientific and medical evidence regarding the
effectiveness of the disputed service.
(2) Nationally recognized professional standards.
(3) Expert opinion.
(4) Generally accepted standards of medical practice.
(5) Treatments that are likely to provide a benefit to a patient
for conditions for which other treatments are not clinically
efficacious.
(c) The organization shall complete its review and make its
determination in writing, and in layperson's terms to the maximum
extent practicable, within 30 days of the receipt of the application
for review and supporting documentation, or within less time as
prescribed by the director. If the disputed health care service has
not been provided and the enrollee's provider or the department
certifies in writing that an imminent and serious threat to the
health of the enrollee may exist, including, but not limited to,
serious pain, the potential loss of life, limb, or major bodily
function, or the immediate and serious deterioration of the health of
the enrollee, the analyses and determinations of the reviewers shall
be expedited and rendered within three days of the receipt of the
information. Subject to the approval of the department, the deadlines
for analyses and determinations involving both regular and expedited
reviews may be extended by the director for up to three days in
extraordinary circumstances or for good cause.
(d) The medical professionals' analyses and determinations shall
state whether the disputed health care service is medically
necessary. Each analysis shall cite the enrollee's medical condition,
the relevant documents in the record, and the relevant findings
associated with the provisions of subdivision (b) to support the
determination. If more than one medical professional reviews the
case, the recommendation of the majority shall prevail. If the
medical professionals reviewing the case are evenly split as to
whether the disputed health care service should be provided, the
decision shall be in favor of providing the service.
(e) The independent medical review organization shall provide the
director, the plan, the enrollee, and the enrollee's provider with
the analyses and determinations of the medical professionals
reviewing the case, and a description of the qualifications of the
medical professionals. The independent medical review organization
shall keep the names of the reviewers confidential in all
communications with entities or individuals outside the independent
medical review organization, except in cases where the reviewer is
called to testify and in response to court orders. If more than one
medical professional reviewed the case and the result was differing
determinations, the independent medical review organization shall
provide each of the separate reviewer's analyses and determinations.
(f) The director shall immediately adopt the determination of the
independent medical review organization, and shall promptly issue a
written decision to the parties that shall be binding on the plan.
(g) After removing the names of the parties, including, but not
limited to, the enrollee, all medical providers, the plan, and any of
the plan's employees or contractors, director decisions adopting a
determination of an independent medical review organization shall be
made available by the department to the public in a searchable
database on the department's Internet Web site, after considering
applicable laws governing disclosure of public records,
confidentiality, and personal privacy.
(h) (1) Information regarding each director decision provided by
the database referenced in subdivision (g) shall include all of the
following:
(A) Enrollee demographic profile information, including age and
gender.
(B) The enrollee diagnosis and disputed health care service.
(C) Whether the independent medical review was for medically
necessary services pursuant to this article or for experimental or
investigational therapies pursuant to Section 1370.4.
(D) Whether the independent medical review was standard or
expedited.
(E) Length of time from the receipt by the independent medical
review organization of the application for review and supporting
documentation to the rendering of a determination by the independent
medical review organization in writing.
(F) Length of time from receipt by the department of the
independent medical review application to the issuance of the
director's determination in writing to the parties that is binding on
the health care service plan.
(G) Credentials and qualifications of the reviewer or reviewers.
(H) The nature of the statutory criteria set forth in subdivision
(b) that the reviewer or reviewers used to make the case decision.
(I) The final result of the determination.
(J) The year the determination was made.
(K) A detailed case summary that includes the specific standards,
criteria, and medical and scientific evidence, if any, that led to
the case decision.
(2) The database referenced in subdivision (g) shall be
accompanied by all of the following:
(A) The annual rate of independent medical review among the total
enrolled population.
(B) The annual rate of independent medical review cases by health
care service plan.
(C) The number, type, and resolution of independent medical review
cases by health care service plan.
(D) The number, type, and resolution of independent medical review
cases by ethnicity, race, and primary language spoken.
(i) This section shall become operative on July 1, 2015.