Independent medical review.

Existing law provides for licensing and regulation of health care service plans by the Department of Managed Health Care. Existing law provides for licensing and regulation of health insurers by the Insurance Commissioner. Existing law requires the department and the commissioner to establish an independent medical review system under which a patient may seek an independent medical review whenever health care services have been denied, modified, or delayed by a health care service plan or health insurer and the patient has previously filed a grievance that remains unresolved after 30 days. Existing law requires medical professionals selected by an independent medical review organization to review medical treatment decisions to meet certain minimum requirements, including that the medical professional be a clinician knowledgeable in the treatment of the patient's medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of treatment under review. Existing law requires a plan or insurer to provide a one-page application form to an enrollee or insured to be used to initiate a review pursuant to these provisions. This bill would make certain changes to requirements applicable to an independent medical review organization, effective on July 1, 2015. The bill would require the medical professional to be a clinician expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating patients with the same or similar condition. The bill would require the application form provided to an enrollee or insured seeking independent review to be one or 2 pages and to include a section designed to collect information on the enrollee's or insured's ethnicity, race, and primary language spoken, which would be provided at the option of the enrollee or insured and used only for statistical purposes. Existing law requires the Director of Managed Health Care and the Insurance Commissioner to adopt the determination of an independent medical review organization as a director or commissioner decision. Existing law requires the decisions to be made available, on request, to the public at cost. Existing law requires certain information to be removed from the decision, including the name of the health plan. This bill would require the decisions to be made available at no charge in a searchable database on the Internet Web site of the Department of Managed Health Care or the Department of Insurance, as applicable, and would require the databases to include other specified information. These requirements would also become effective on July 1, 2015.