External review process of health benefit plan decisions

2. Under current law, access to the independent review process must be provided for a reduction, denial, or termination of treatment or payment for treatment related to the admission to a facility, the availability of care, or the continued stay in a facility (adverse determination) if the amount of the reduction or the cost of the denied or terminated treatment exceeds $250, adjusted in accordance with the consumer price index. Also under current law, access to the independent review process must be provided for a denial of treatment on the basis that the treatment is experimental (experimental treatment determination) if the cost of the denied treatment exceeds $250, adjusted in accordance with the consumer price index. The bill removes the minimum dollar amount for both adverse determinations and experimental treatment determinations.

3. Under current law, the insured selects an independent review organization and notifies the insurer both that he or she is requesting an independent review and which independent review organization he or she has selected to conduct the review.

Under the bill, the insured notifies both the insurer and the commissioner of insurance (commissioner) that he or she is requesting an independent review, and the commissioner then, within two business days, randomly selects the independent review organization that will conduct the review.

4. Current law provides a timeline within which an insurer must submit information to the independent review organization and the independent review organization must make a decision. The bill generally does not change the timeline, but specifies that in no case may the independent review organization send its written decision to the insured and insurer more than 60 days after it was notified of its selection by the commissioner.

5. Current law provides an expedited timeline for independent reviews when the independent review organization determines that, due to the insured's health condition, following the usual timeline would jeopardize the insured's life or health (urgent matters). The bill eliminates the expedited timeline and provides, simply, that in urgent matters the independent review organization must notify the insured and insurer of its decision no more than four business days after it was notified of its selection by the commissioner. Additionally, if notification to the insured and insurer of its decision was not in writing, the independent review organization must send written confirmation of its decision within 48 hours after providing the initial notice of its decision.

6. Finally, current law provides that a decision regarding an experimental treatment determination is limited to a determination of whether the proposed treatment is experimental and specifies what an independent review organization must find to determine that a treatment is not experimental and to find in favor of the insured. The bill does not change what an independent review organization must find to find in favor of the insured, but removes the restriction that an experimental treatment determination is limited to a determination of whether the proposed treatment is experimental and requires that an independent review of an experimental treatment determination must provide for all the same protections that apply in an independent review of an adverse determination.