Health care coverage reporting.

Assembly Member Ortega's health care transparency legislation would require California health insurers and plans to report detailed monthly data about denied claims and make this information publicly available. The measure expands existing financial reporting requirements to include specific metrics about claim denials, including the total number processed, reasons for denials, and outcomes of appeals.

Under the proposed changes, health plans and insurers must report monthly statistics on denied claims broken down by multiple categories, including out-of-network services, excluded benefits, lack of prior authorization, and medical necessity determinations. The reporting must also indicate how many denied claims were processed using artificial intelligence systems and track both internal and external appeals outcomes. The Departments of Managed Health Care and Insurance would publish this claims data on their websites for each regulated entity.

The legislation maintains current timeframes for submitting annual financial statements while adding the new monthly claims reporting elements. Health plans must continue providing audited financial reports within 120 days of their fiscal year end, and insurers must report covered lives data by March 1 annually. The measure specifies that violations of these requirements by health plans would constitute a crime under existing law.