Health care coverage: utilization review: peer-to-peer review.

Plain English Breakdown

The official source material does not provide specific details on how the bill will be funded or what happens if there are no available reviewers in the same specialty as the requesting provider within the required time frame.

Health Care Coverage: Peer-to-Peer Review

AB-510 requires health care service plans and disability insurers to provide faster peer reviews of decisions that deny, delay, or modify medical services based on necessity.

What This Bill Does

• Requires a provider to request a review by another licensed physician or healthcare professional if a decision denies, delays, or modifies a medical service based on medical necessity.
• Ensures the reviewer is from the same specialty as the requesting provider and can evaluate specific clinical issues.
• Sets strict timelines for these reviews: 2 business days unless there's an urgent health threat, then it must be done immediately.
• If the review isn't completed in time, the original request for medical services is automatically approved.

Who It Names or Affects

• Health care service plans and disability insurers
• Providers who make requests for reviews
• Enrollees or insured individuals whose medical needs are affected by these decisions

Terms To Know

Utilization review

A process used by health care service plans and disability insurers to decide if a requested medical service is necessary.

Peer-to-peer review

When another doctor or healthcare professional reviews a decision about denying, delaying, or modifying a medical service based on its necessity.

Limits and Unknowns

• The bill does not specify how the new peer-to-peer review system will be funded.
• It is unclear what happens if there are no available reviewers in the same specialty as the requesting provider within the required time frame.

Official Summary Text

AB 510, as amended, Addis.
Health care coverage: utilization review:
appeals and grievances.
peer-to-peer review.
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.
Existing law requires a health care service plan or disability insurer to include in a response regarding decisions to deny, delay, or modify health care services, among other
things, information on how the provider, enrollee, or insured may file a grievance or appeal with the plan or insurer. Existing law requires a health care service plan’s grievance system to resolve grievances within 30 days, except as specified. Existing law requires a contract between a health insurer and a provider to contain provisions requiring a dispute resolution mechanism, and requires an insurer to resolve each provider dispute within 45 working days, as specified.
This
bill would, upon request, require that an appeal or grievance regarding
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,
be reviewed by
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
review of a grievance or appeal by
a licensed health care professional
to be the reviewer
if the provider requesting
peer-to-peer
review is not a physician. The bill, notwithstanding
the above-described timelines,
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.
The bill would make conforming changes to related provisions.
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.

Current Bill Text

Download Bill PDF