28 CA ADC § 1300.70.4


      28 CCR s 1300.70.4

      Cal. Admin. Code tit. 28, s 1300.70.4


      CALIFORNIA CODE OF REGULATIONS
      TITLE 28. MANAGED HEALTH CARE
      DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
      CHAPTER 2. HEALTH CARE SERVICE PLANS
      ARTICLE 8. SELF-POLICING PROCEDURES
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.70.4. Independent Medical Reviews Experimental and Investigational 
      Therapies.

      (a) Enrollees of a health care service plan may request an independent 
      medical review pursuant to sections 1370.4, 1374.30 through 1374.34 of the 
      Act and section 1300.74.30 of title 28 when the plan has denied a therapy 
      or medical service that would otherwise be covered based on the plan's 
      determination that the therapy or medical service is experimental or 
      investigational. This eligibility also applies to Medicare enrollees to 
      the extent it does not conflict with federal law.

      (b) At the time of the plan's denial of coverage for experimental or 
      investigational therapy, or denial of urgent care or emergency services, 
      as defined in section 1300.67(g)(2), the plan shall notify the enrollee of 
      the ability to seek independent medical review.

      (1) The notification must include, at a minimum, information on the 
      independent medical review process, an application and envelope addressed 
      to the Department, the physician certification form and the Department's 
      toll-free information number.

      (2) Pursuant to Health and Safety Code section 1368.03(a), the Department 
      does not require that an enrollee participate in the plan's grievance 
      system prior to seeking independent medical review.

      (c) Included with the enrollee's application to the Department for 
      independent medical review shall be a copy of the plan or contracted 
      provider's written denial of the therapy or medical service based on the 
      determination that the therapy or service is experimental or 
      investigational.

      (d) A certification from the enrollee's treating physician shall be 
      included with the application for independent medical review. The 
      physician's certification shall be on a form from the Department entitled, 
      "Physician Certification Experimental/ Investigational Denials" (DMHC/IMR 
      110-11/27/00), or contain all of the following information:

      (1) The enrollee has a condition as defined in Health and Safety Code 
      section 1370.4(a)(1):

      (2) Background information including the name of the enrollee and the 
      health plan; the physician's name, specialty, board certification, 
      address, telephone, and fax number; whether the physician is contracted 
      with the plan; the enrollee's medical condition; and the specific drug, 
      device, procedure, or other therapy recommended or requested for the 
      enrollee's medical condition.

      (3) For non-contracting physicians, the certification shall also include 
      the following:

      (A) The physician's license, board-certification or board eligibility to 
      practice in the area appropriate to treat the enrollee's condition; and,

      (B) Reference to, or copies of, two documents from the medical or 
      scientific literature, specified in section 1370.4(d) of the Act.

      (4) The following statement and physician's signature: "I certify that the 
      requested therapy is likely to be more beneficial than any standard 
      therapy. The information provided herein is true and correct;"

      (5) Where expedited review is requested the certification shall include a 
      statement that imminent and serious threat to the health of the enrollee 
      exists pursuant to Health and Safety Code section 1374.31, or the proposed 
      therapy would be significantly less effective if not promptly initiated; 
      and

      (6) Attachments, including any additional references or copies of medical 
      and/or scientific literature considered relevant to the requested therapy 
      and any other information relevant to the request.

      (e) Incomplete applications will not be referred to an independent medical 
      review organization. However, the Department may waive this requirement in 
      exceptional or compelling circumstances where the need for a prompt 
      determination precludes obtaining all information in writing. In cases 
      accepted for an urgent review, the enrollee's physician must certify in 
      writing, at a minimum, that the enrollee has a life-threatening or 
      seriously debilitating condition, as defined in Health and Safety Code 
      section 1370.4(a), that the requested therapy is likely to be more 
      beneficial to the enrollee than any available standard therapy and 
      describe the medical and scientific evidence relied upon in making the 
      recommendation.


      


      Note: Authority cited: Section 1344, Health and Safety Code. Reference: 
      Section 1370.4, Health and Safety Code. 


       HISTORY 
         
      1. New section filed 11-12-2002; operative 12-12-2002 (Register 2002, No.
      46).

      2. Amendment of subsections (a) and (b) filed 6-17-2005; operative 
      7-17-2005 
      (Register 2005, No. 24).
      28 CA ADC s 1300.70.4

      END OF DOCUMENT

      (C) Copyright 2006, Result Oriented Marketing, Inc.
      For Further Assistance Visit : www.mcmillanlaw.us and www.fearnotlaw.com