Health care coverage: prior authorization.

Plain English Breakdown

The official source does not specify that violating the new timelines would be a criminal offense, only that it would be a violation of the act which could result in other penalties. The term 'Utilization Review' was removed as its definition and relevance were not fully supported by the provided text.

Health Care Coverage: Prior Authorization

AB-512 changes the time limits for health care service plans and disability insurers to review requests for medical services, making decisions faster in urgent cases but excluding Medi-Cal managed care plans from these new rules.

What This Bill Does

• Changes the timeline for prior or concurrent authorization requests to no more than 3 business days if submitted electronically, or 5 business days if not electronic.
• Requires a decision within 24 hours for urgent cases if submitted electronically, and 48 hours if not electronic.
• Excludes Medi-Cal managed care plans from the new timeline requirements.

Who It Names or Affects

• Health care service plans
• Disability insurers
• Enrollees and insured individuals

Terms To Know

Prior Authorization

A process where a health plan or insurer reviews and approves, modifies, delays, or denies requests for medical services based on their necessity.

Limits and Unknowns

• Medi-Cal managed care plans are not included in these new timeline requirements.
• It is unclear if lawmakers will override the governor's veto on this bill.

Official Summary Text

AB 512, Harabedian.
Health care coverage: prior authorization.
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 provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including pursuant to contracts with various types of managed care plans. Existing law generally authorizes a health care service plan, including a Medi-Cal managed care plan, or disability insurer to use utilization review, 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. For a request prior to or concurrent with the provision of health care services, existing law requires utilization review decisions to be made within 5 business days from the plan’s or insurer’s receipt of the information reasonably necessary and requested by the plan or insurer to make the determination, or within 72 hours if the enrollee or insured faces an imminent and serious threat to their health or the normal timeframe would be detrimental to their life or health, as specified.
This bill would change the timeline for prior or concurrent authorization requests to no more than 3 business days from the plan’s or insurer’s receipt via electronic submission, or 5 business days from receipt via submission that is not electronic, of the information reasonably necessary and requested by the plan or insurer to make the determination. The bill would require a utilization review decision to be made
within 24 hours from receipt of a prior or concurrent authorization request via electronic submission, or 48 hours from receipt via submission that is not electronic, if the enrollee or insured faces an imminent and serious threat to their health or the normal timeframe would be detrimental to their life or health. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program. The bill would exclude Medi-Cal managed care plans from the above-described timeline changes.
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