Health care coverage: utilization review criteria. Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to establish criteria or guidelines that meet specified requirements to be used to determine whether or not to authorize, modify, or deny health care services.
This bill would authorize the Department of Managed Health Care and the Insurance Commissioner, as appropriate, to review a plan’s or insurer’s clinical criteria, guidelines, and utilization management policies to ensure compliance with existing law. If the criteria and guidelines are not in compliance with existing law, the bill would authorize the Director of the Department of Managed Health Care or the commissioner to issue a corrective action and send the matter to enforcement, if necessary.