California Health and Safety Code

§ 1374.33

HSC § 1374.33 Effective Jan 1, 2013Div. 2 · Ch. 2.2 · Art. 5.55

Statute text

(a)Upon receipt of information and documents related to a case, the medical professional reviewer or reviewers selected to conduct the review by the independent medical review organization shall promptly review all pertinent medical records of the enrollee, provider reports, as well as any other information submitted to the organization as authorized by the department or requested from any of the parties to the dispute by the reviewers. If reviewers request information from any of the parties, a copy of the request and the response shall be provided to all of the parties. The reviewer or reviewers shall also review relevant information related to the criteria set forth in subdivision (b).

(b)Following its review, the reviewer or reviewers shall determine whether the disputed health care service was medically necessary based on the specific medical needs of the enrollee and any of the following:

(1)Peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service.

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Legislative history

Repealed (in Sec. 5) and added by Stats. 2012, Ch. 872, Sec. 6. (SB 1410) Effective January 1, 2013. Section operative July 1, 2015, by its own provisions.