SB 551

Under current law, a health insurer must have an internal grievance procedure

and an independent review procedure whereby an insured person may appeal

certain types of coverage denials to an independent review organization. This bill

makes the following changes to the independent review process that health insurers

must provide:

1. Under current law, with some exceptions, an insured must exhaust the

internal grievance procedure before the insured may request an independent review

of a coverage denial. The bill adds as another exception to that requirement that the

insurer or another entity other than the insured did not meet all of the timelines

required under the internal grievance procedure.

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