Plain English Breakdown
The official text does not define exactly what constitutes an 'imminent and serious threat,' leaving that determination open.
Faster Peer-to-Peer Reviews for Health Care Appeals
This law requires health plans to finish peer reviews of denied medical services within two business days, or the service is automatically approved.
What This Bill Does
- Requires a licensed doctor with similar training to review appeals when a plan denies, delays, or changes care based on medical necessity.
- Allows a non-physician health professional to conduct the review if the original provider was not a physician.
- Sets a deadline of 2 business days for these reviews unless an emergency requires faster action appropriate for the patient's condition.
- Automatically approves the requested service if the plan fails to finish the review by the required time.
Who It Names or Affects
- Health care service plans and disability insurers
- Doctors and other licensed health professionals who request services for patients
- Patients enrolled in these insurance plans
Terms To Know
- Peer-to-peer review
- A process where a doctor or professional from the insurance plan reviews a decision with the patient's provider to discuss why care was denied.
- Utilization review
- The check an insurer does to decide if a medical service is necessary before approving it.
Limits and Unknowns
- The law applies only when the denial or delay was based in whole or in part on medical necessity.
- Specific rules for what counts as an 'imminent and serious threat' are not detailed in this summary text.
- This bill does not change how long it takes to resolve other types of complaints that do not involve peer-to-peer reviews.