Health care coverage: utilization review: peer-to-peer review., the official text

An act to add Section 1367.017 to the Health and Safety Code, and to add Section 10123.138 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL'S DIGEST

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of disability insurers by the Department of Insurance. Existing law generally authorizes a health care service plan or disability insurer to use prior authorization and other utilization review or utilization management functions, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity.
This bill, upon communication of a decision by a health care service plan or health insurer delaying, denying, or modifying a health care service based in whole or in part on medical necessity, would authorize a provider to request review of the decision by a licensed physician, or a licensed health care professional under specified circumstances, who is competent to evaluate the specific clinical issues involved in the health care service being requested, and is of the same or similar specialty as the requesting provider. The bill would authorize a licensed health care professional to be the reviewer if the provider requesting peer-to-peer review is not a physician. The bill, notwithstanding any other law, would require these reviews to occur within 2 business days, or if an enrollee or insured faces an imminent and serious threat to their health, within a timely fashion appropriate for the nature of the enrollee’s or insured’s condition, as specified. If a health care service plan or health insurer fails to meet those timelines, the bill would deem the request for the health care service as approved and supersede any prior delay, denial, or modification.
Because a violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

The people of the State of California do enact as follows:

SECTION 1.
Section 1367.017 is added to the Health and Safety Code, to read:
1367.017.
(a) Upon communication of a decision by a health care service plan delaying, denying, or modifying a health care service based in whole or in part on medical necessity, a provider may request a review by a peer physician or, if authorized pursuant to subdivision (d), a peer health care professional. The peer-to-peer review process shall meet both of the following requirements:
(1) Upon a request for peer-to-peer review pursuant to this section, a health care service plan shall directly and expeditiously connect the requesting health care provider with a peer physician or, if authorized pursuant to subdivision (d), a peer health care professional without requiring the requesting provider to communicate with any additional health care service plan employees or other individuals acting on behalf of the health care service plan.
(2) Notwithstanding any other law, a peer-to-peer review requested pursuant to this section shall occur within two business days of the request. However, if the enrollee faces an imminent and serious threat to their health as described in paragraph (2) of subdivision (h) of Section 1367.01, a peer-to-peer review requested pursuant to this section shall occur in a timely fashion appropriate for the nature of the enrollee’s condition, not to exceed 24 hours after the request.
(b) If a health care service plan fails to meet the review timelines set forth in paragraph (2) of subdivision (a), the request for the health care service shall be deemed approved and supersede any prior delay, denial, or modification.
(c) A peer-to-peer review may be performed by a health care service plan’s contracted specialist reviewer, provided the reviewer is a peer physician or, if authorized pursuant to subdivision (d), a peer health care professional.
(d) If a provider requesting peer-to-peer review pursuant to this section is not a physician, a peer health care professional may be the reviewer.
(e) For purposes of this section, the following definitions apply:
(1) “Peer health care professional” means a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care service being requested, and is of the same or similar specialty as the requesting provider.
(2) “Peer physician” means a licensed physician who is competent to evaluate the specific clinical issues involved in the health care service being requested, and is of the same or similar specialty as the requesting provider.

SEC. 2.
Section 10123.138 is added to the Insurance Code, to read:
10123.138.
(a) Upon communication of a decision by a health insurer delaying, denying, or modifying a health care service based in whole or in part on medical necessity, a provider may request a review by a peer physician or, if authorized pursuant to subdivision (d), a peer health care professional. The peer-to-peer review process shall meet both of the following requirements:
(1) Upon a request for peer-to-peer review pursuant to this section, a health insurer shall directly and expeditiously connect the requesting health care provider with a peer physician or, if authorized pursuant to subdivision (d), a peer health care professional without requiring the requesting provider to communicate with any additional health insurer employees or other individuals acting on behalf of the health insurer.
(2) Notwithstanding any other law, a peer-to-peer review requested pursuant to this section shall occur within two business days of the request. However, if the insured faces an imminent and serious threat to their health as described in paragraph (2) of subdivision (h) of Section 10123.135, a peer-to-peer review requested pursuant to this section shall occur in a timely fashion appropriate for the nature of the insured’s condition, not to exceed 24 hours after the request.
(b) If a health insurer fails to meet the review timelines set forth in paragraph (2) of subdivision (a), the request for the health care service shall be deemed approved and supersede any prior delay, denial, or modification.
(c) A peer-to-peer review may be performed by a health insurer’s contracted specialist reviewer, provided the reviewer is a peer physician or, if authorized pursuant to subdivision (d), a peer health care professional.
(d) If a provider requesting peer-to-peer review pursuant to this section is not a physician, a peer health care professional may be the reviewer.
(e) For purposes of this section, the following definitions apply:
(1) “Peer health care professional” means a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care service being requested, and is of the same or similar specialty as the requesting provider.
(2) “Peer physician” means a licensed physician who is competent to evaluate the specific clinical issues involved in the health care service being requested, and is of the same or similar specialty as the requesting provider.

SEC. 3.
No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.