California Health and Safety Code

§ 1363.5

HSC § 1363.5 Effective Jan 1, 2001Div. 2 · Ch. 2.2 · Art. 4

Statute text

(a)A plan shall disclose or provide for the disclosure to the director and to network providers the process the plan, its contracting provider groups, or any entity with which the plan contracts for services that include utilization review or utilization management functions, uses to authorize, modify, or deny health care services under the benefits provided by the plan, including coverage for subacute care, transitional inpatient care, or care provided in skilled nursing facilities. A plan shall also disclose those processes to enrollees or persons designated by an enrollee, or to any other person or organization, upon request. The disclosure to the director shall include the policies, procedures, and the description of the process that are filed with the director pursuant to subdivision (b) of Section 1367.01.

(b)The criteria or guidelines used by plans, or any entities with which plans contract for services that include utilization review or utilization management functions, to determine whether to authorize, modify, or deny health care services shall:

(1)Be developed with involvement from actively practicing health care providers.

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Legislative history

Amended by Stats. 2000, Ch. 1067, Sec. 6. Effective January 1, 2001.