28 CA ADC § 1300.74.30
28 CCR s 1300.74.30
Cal. Admin. Code tit. 28, s 1300.74.30
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 1300.74.30. Independent Medical Review System.
(a) Plan enrollees may request independent medical review pursuant to this
regulation for decisions that are eligible for independent medical review
under Article 5.55 and section 1370.4 of the Act. The independent medical
review process shall resolve decisions that deny, modify, or delay health
care services, that deny reimbursement for urgent or emergency services or
that involve experimental or investigational therapies. Specialized plans
shall provide for independent medical reviews under this section if a
covered service relates to the practice of medicine or is provided
pursuant to a contract with a health plan providing medical, surgical and
hospital services. The Department shall be the final arbiter when there is
a question as to whether a dispute over a health care service is eligible
for independent medical review, and whether extraordinary and compelling
circumstances exist that waive the requirement that the enrollee first
participate in the plan's grievance system.
(b) An enrollee may apply for an independent medical review under the
conditions specified in Section 1374.30(j) of the Act. The Department may
waive the requirement that the enrollee participate in the plan's
grievance process if the Department determines that extraordinary and
compelling circumstances exist, which include, but are not limited to,
serious pain, the potential loss of life, limb or major bodily function,
or the immediate, and serious deterioration of the health of the enrollee.
(c) In cases involving a claim for out of plan emergency or urgent
services that a provider determined were medically necessary, the
independent medical review shall determine whether the services were
emergency or urgent services necessary to screen and stabilize the
enrollee's condition. For purposes of this section "emergency services"
are services for emergency medical conditions as defined in section
1300.71.4 of title 28, and "urgent services" are all services, except
emergency services, where the enrollee has obtained the services without
prior authorization from the plan, or from a contracting provider.
(d) Applications for independent medical review shall be submitted on a
one-page form entitled Independent Medical Review Application (DMHC IMR
11/00), which is incorporated by reference, and shall be provided by the
Department. The form shall contain a signed release from the enrollee, or
a person authorized pursuant to law to act on behalf of the enrollee,
authorizing release of medical and treatment information. Additionally,
the enrollee may provide any relevant material or documentation with the
application including, but not limited to:
(1) A copy of the adverse determination by the plan or contracting
provider notifying the enrollee that the request for health care services
was denied, delayed or modified, in whole or in part, based on the
determination that the service was not medically necessary;
(2) Medical records, statements from the enrollee's provider or other
documents establishing that the dispute is eligible for review;
(3) A copy of the grievance requesting the health care service or benefit
filed with the plan or any entity with delegated authority to resolve
grievances, and the response to the grievance, if any;
(4) If expedited review is requested for a decision eligible for
independent medical review pursuant to Article 5.55 of the Act, the
application shall include, a certification from the enrollee's physician
or provider indicating that an imminent and serious threat to the health
of the enrollee exists. If expedited review is requested for a decision
eligible for independent medical review pursuant to section 1370.4 of the
Act, the application shall include a certification from the enrollee's
physician that the proposed therapy would be significantly less effective
if not promptly initiated.
(e) If additional information is needed to complete an application or to
determine the enrollee's eligibility for independent medical review, the
Department shall advise the enrollee or the enrollee's representative, the
enrollee's provider, the enrollee's health care plan or the enrollee's
attending physician, as appropriate, by the most efficient means
available.
(f) The Department shall evaluate complaints received under subsection (b)
of Section 1368 of the Act and applications submitted under this
regulation and determine whether the enrollee is eligible for an
independent medical review. The Department's determination will consider
all information provided to the Department, the enrollee's medical
condition and the disputed health care service. If the Department
determines that the case should not be referred to independent medical
review, the request shall be considered a complaint under subsection (b)
of Section 1368 and sections 1300.68 and 1300.68.01. The enrollee or the
enrollee's representative, health plan and any involved provider shall be
advised of the Department's determination.
(1) The request for independent medical review shall be filed with the
Department within six months of the plan's written response to the
enrollee's grievance. The six-month period does not begin to run until the
enrollee, or the enrollee's representative, has been properly notified in
writing of the plan's resolution of the grievance. Applications will not
be rejected as untimely solely because the enrollee, the enrollee's
provider, or the plan failed to submit supporting documentation. Requests
for extensions or late applications shall be approved if a timely
submission was reasonably impaired by inadequate notice of the independent
medical review process or by the applicant's medical circumstances.
(2) An application will not be eligible for independent medical review if
the enrollee's complaint has previously been submitted and reviewed by the
Department. Exceptions may be approved if the application for independent
medical review includes medical records and a statement from the
enrollee's physician or provider demonstrating significant changes in the
enrollee's medical condition or in medical therapies available have
occurred since the Department's disposition of the complaint.
(3) Enrollees of Medi-Cal health care service plans are eligible for an
independent medical review if the enrollee has not presented the disputed
health care service for resolution by the Medi-Cal fair hearing process.
Reviews shall be conducted in accordance with the statutes and regulations
of the Medi-Cal program.
(4) This regulation applies to Medicare enrollees, to the extent the
regulation does not conflict with federal law, including 42 USCS s
1395w-26 (2004).
(g) Except for Medi-Cal enrollees, and Medicare enrollees exempted by
federal law, as described at subsection (f)(4), the independent medical
review system established pursuant to this section shall be the exclusive
independent medical review process offered to enrollees for disputes
involving the medical necessity of covered health care services. Nothing
in this section shall preclude a health plan from offering other
independent review processes for disputes that do not involve medical
necessity.
(h) When the Department finds that a plan fails to advise an enrollee of
the availability of independent medical review as required under Health
and Safety Code section 1374.30(i), or engages in a practice of
mischaracterizing determinations substantially based on medical necessity
as coverage decisions, or otherwise interferes with the rights of
enrollees to obtain independent medical review, the Department shall
impose administrative penalties on the plan in accordance with the Act.
(i) The director shall notify the enrollee and the enrollee's health care
plan if an application for independent medical review has been accepted
within seven (7) calendar days of receipt of a completed application for a
routine request and within 48 hours of receipt of a completed application
for an expedited review. The notification shall identify the independent
medical review organization, whether the review shall be conducted on an
expedited or routine basis and other information deemed necessary by the
Department. The director shall also transmit to the enrollee's health care
plan a copy of the enrollee's signed release of medical and treatment
information and copies of all other materials submitted with the
enrollee's application.
(j) Following receipt of the Department's notification that an application
for independent medical review has been assigned to an independent medical
review organization, the plan shall provide the organization with all
information that was considered in relation to the disputed health care
service, the enrollee's grievance and the plan's determination. The plan
shall forward all information to the medical review organization within
three (3) business days for a regular review and within one (1) calendar
day in the case of an expedited review.
(1) Unless otherwise advised in the notification or by the assigned review
organization, the plan shall submit a complete set of the materials
described below for the independent review organization.
(A) A copy of all correspondence from and received by the plan concerning
the disputed health care service, including but not limited to, any
enrollee grievance relating to the requested service;
(B) A complete and legible copy of all medical records and other
information used by the plan in making its decision regarding the disputed
health care service. An additional copy of medical records shall be
submitted for each reviewer.
(C) A copy of the cover page of the evidence of coverage and complete
pages with the referenced sections highlighted or underlined sections, if
the evidence of coverage was referenced in the plan's resolution of the
enrollee's grievance;
(D) The plan's response to any additional issues raised in the enrollee's
application for independent medical review.
(2) The plan shall promptly provide the enrollee with an annotated list of
all documents submitted to the independent medical review organization,
together with information on how copies may be requested.
(k) Plans shall be responsible for providing additional information as
follows:
(1) Any medical records or other relevant matters not available at the
time of the Department's initial notification, or that result from the
enrollee's on-going medical care or treatment for the medical condition or
disease under review. Such matters shall be forwarded as soon as possible
upon receipt by the health plan, not to exceed five (5) business days in
routine cases or one (1) calendar day in expedited cases.
(2) Additional medical records or other information requested by the IMR
organization shall be sent within five (5) business days in routine cases
or one (1) calendar day in expedited cases. In expedited reviews, the
health care plan shall immediately notify the enrollee and the enrollee's
health care provider by telephone or facsimile to identify and request the
necessary information, followed by written notification, when the request
involves materials not in the possession of the plan or its contracting
providers.
(l) Each assigned reviewer shall issue a separate written analysis of the
case, explaining the determination made, using plain English where
possible. The analysis shall describe how the determination relates to the
enrollee's medical condition and history, relevant medical records and
other documents considered, and references to the specific medical and
scientific evidence listed in Sections 1370.4(d) or 1374.33(b) of the Act,
as applicable. For requests made pursuant to Article 5.55 of the Act,
reviewers shall determine whether the disputed service is medically
necessary for the enrollee. For requests made pursuant to section 1370.4
of the Act, the reviewers shall determine whether the requested therapy is
likely to be more beneficial for the enrollee then other available
standard therapies, and whether the plan shall provide the requested
therapy. Reviews based on section 1300.70.4 of these regulations shall
also reference the medical and scientific evidence considered in assessing
whether the requested health care service is likely to be more beneficial
than other available standard therapies. The analysis may also discuss the
risks and benefits considered by the reviewer in considering proposed and
standard treatments.
(m) The Department, the enrollee, or his/her representative may withdraw a
case from the independent review system at any time. The plan may seek
withdrawal of the case from the review system by providing the disputed
health care service, subject to the concurrence of the enrollee.
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Sections 1370.4, 1374.30 and 1374.33, Health and Safety Code.
HISTORY
1. New section filed 2-18-2003; operative 3-20-2003 (Register 2003, No.
8).
2. New subsection (f)(4) and amendment of subsection (g) filed 7-25-2005;
operative 8-24-2005 (Register 2005, No. 30).
28 CA ADC s 1300.74.30
END OF DOCUMENT
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