Health care coverage: utilization review: peer-to-peer review.

Assembly Member Addis's health care coverage legislation establishes new peer review requirements when health plans or insurers deny, delay, or modify services based on medical necessity. The measure creates direct pathways for providers to challenge coverage decisions through consultations with qualified peer physicians or health professionals.

Under the bill's provisions, health plans and insurers must connect requesting providers directly with peer reviewers who practice in the same or similar specialty and are competent to evaluate the specific clinical issues. These peer-to-peer reviews must occur within two business days of the request, or within 24 hours for cases involving imminent and serious health threats. If plans or insurers fail to meet these timelines, the original service request receives automatic approval, overriding any prior denial.

The legislation defines peer reviewers as either licensed physicians or, when the requesting provider is not a physician, licensed health care professionals with relevant clinical expertise. The requirements apply equally to both health care service plans regulated under the Knox-Keene Act and to health insurers overseen by the Department of Insurance, creating uniform standards across California's health coverage system.