Bill > AB510

This bill introduces new requirements for peer-to-peer review processes in health care service plans and health insurers when a health care service is delayed, denied, or modified based on medical necessity. Under the new law, when a health care provider requests a review, the health care service plan or insurer must directly connect the requesting provider with a peer physician or peer health care professional (someone in the same or similar specialty who is competent to evaluate the specific clinical issues) within two business days. In urgent cases where a patient faces an imminent and serious health threat, the review must occur within 24 hours. If the health care service plan or insurer fails to meet these timelines, the request for health care service will be automatically approved, overriding any previous delay, denial, or modification. The bill allows for peer health care professionals to conduct the review if the requesting provider is not a physician. These provisions aim to streamline and expedite the review process for health care service decisions, ensuring that providers can quickly challenge decisions they believe are not medically appropriate. The bill also specifies that no additional state reimbursement is required for implementing these new requirements.

Budget and Finance, Health and Social Services

https://leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202520260AB510