Health care coverage: utilization review: appeals and grievances.

Assembly Member Addis proposes new requirements for health plans and insurers to expedite medical necessity appeals through peer review processes. Under the legislation, appeals of denied or delayed health services must be reviewed by a licensed physician or healthcare professional of the same specialty as the requesting provider within two business days, or within 24 hours for cases involving serious health threats.

The measure establishes direct provider-to-peer reviewer communication channels and automatic approval of requested services if plans fail to meet review deadlines. For non-physician providers, appeals may be reviewed by peer healthcare professionals competent in the relevant clinical specialty. The bill maintains existing 30-day grievance resolution timeframes for health plans and 45-day dispute resolution periods for insurers, while adding these expedited peer review requirements.

The provisions apply to both health care service plans regulated by the Department of Managed Health Care and health insurers overseen by the Department of Insurance. Plans and insurers must incorporate these new appeal mechanisms into their existing grievance systems and provider dispute resolution processes. The measure designates violations by health plans as criminal offenses under state law.