Article 9.5. Claims Reviewers of California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 9.5.
Health care service plans shall, upon rejecting a claim
from a health care provider or a patient, and upon their demand,
disclose the specific rationale used in determining why the claim was
rejected. Nothing in this section is intended to expand or restrict
the ability of a health care provider or a patient from having health
care coverage approved in advance of services.
Compensation of a person retained by a health care service
plan to review claims for health care services shall not be based on
either of the following:
(a) A percentage of the amount by which a claim is reduced for
(b) The number of claims or the cost of services for which the
person has denied authorization or payment.
This article does not apply to services or benefits
provided pursuant to Medi-Cal, including services or benefits
provided under Chapters 7 (commencing with Section 14000) and 8
(commencing with Section 14200) of Part 3 of Division 9 of the
Welfare and Institutions Code.