Bill Text: CA SB1410 | 2011-2012 | Regular Session | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Independent medical review.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2012-09-30 - Chaptered by Secretary of State. Chapter 872, Statutes of 2012. [SB1410 Detail]
Download: California-2011-SB1410-Introduced.html
Bill Title: Independent medical review.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2012-09-30 - Chaptered by Secretary of State. Chapter 872, Statutes of 2012. [SB1410 Detail]
Download: California-2011-SB1410-Introduced.html
BILL NUMBER: SB 1410 INTRODUCED
BILL TEXT
INTRODUCED BY Senator Hernandez
FEBRUARY 24, 2012
An act to amend Sections 1374.32 and 1374.33 of the Health and
Safety Code, and to amend Sections 10169.2 and 10169.3 of the
Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1410, as introduced, Hernandez. Independent medical review.
Existing law provides for licensing and regulation of health care
service plans by the Department of Managed Health Care. Existing law
provides for licensing and regulation of health insurers by the
Insurance Commissioner. Existing law requires the department and the
commissioner to establish an independent medical review system under
which a patient may seek an independent medical review whenever
health care services have been denied, modified, or delayed by a
health care service plan or health insurer and the patient has
previously filed a grievance that remains unresolved after 30 days.
Existing law requires medical professionals selected by an
independent medical review organization to review medical treatment
decisions to meet certain minimum requirements, including that the
medical professional be a clinician knowledgeable in the treatment of
the patient's medical condition, knowledgeable about the proposed
treatment, and familiar with guidelines and protocols in the area of
treatment under review.
This bill would instead require the medical professional to be a
clinician expert in the treatment of the enrollee's medical condition
and knowledgeable about the proposed treatment through recent or
current actual clinical experience treating patients with the same or
similar condition.
Existing law requires the Director of Managed Health Care and the
Insurance Commissioner to adopt the determination of an independent
medical review organization as a director or commissioner decision.
Existing law requires the decisions to be made available, on request,
to the public at cost. Existing law requires certain information to
be removed from the decision, including the name of the health plan.
This bill would require the decisions to be made available at no
charge on the Internet Web site of the Department of Managed Health
Care or Department of Insurance, as applicable. The bill would delete
the requirement to remove the name of the health plan.
This bill would also require the 2 departments to consult with
each other regarding the establishment of a common searchable
database for these decisions, and would specify the information that
is to be made available in that regard.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1374.32 of the Health and Safety Code is
amended to read:
1374.32. (a) By January 1, 2001, the The
department shall contract with one or more independent medical
review organizations in the state to conduct reviews for purposes of
this article. The independent medical review organizations shall be
independent of any health care service plan doing business in this
state. The director may establish additional requirements, including
conflict-of-interest standards, consistent with the purposes of this
article, that an organization shall be required to meet in order to
qualify for participation in the Independent Medical Review System
and to assist the department in carrying out its responsibilities.
(b) The independent medical review organizations and the medical
professionals retained to conduct reviews shall be deemed to be
medical consultants for purposes of Section 43.98 of the Civil Code.
(c) The independent medical review organization, any experts it
designates to conduct a review, or any officer, director, or employee
of the independent medical review organization shall not have any
material professional, familial, or financial affiliation, as
determined by the director, with any of the following:
(1) The plan.
(2) Any officer, director, or employee of the plan.
(3) A physician, the physician's medical group, or the independent
practice association involved in the health care service in dispute.
(4) The facility or institution at which either the proposed
health care service, or the alternative service, if any, recommended
by the plan, would be provided.
(5) The development or manufacture of the principal drug, device,
procedure, or other therapy proposed by the enrollee whose treatment
is under review, or the alternative therapy, if any, recommended by
the plan.
(6) The enrollee or the enrollee's immediate family.
(d) In order to contract with the department for purposes of this
article, an independent medical review organization shall meet all of
the following requirements:
(1) The organization shall not be an affiliate or a subsidiary of,
nor in any way be owned or controlled by, a health plan or a trade
association of health plans. A board member, director, officer, or
employee of the independent medical review organization shall not
serve as a board member, director, or employee of a health care
service plan. A board member, director, or officer of a health plan
or a trade association of health plans shall not serve as a board
member, director, officer, or employee of an independent medical
review organization.
(2) The organization shall submit to the department the following
information upon initial application to contract for purposes of this
article and, except as otherwise provided, annually thereafter upon
any change to any of the following information:
(A) The names of all stockholders and owners of more than 5
percent of any stock or options, if a publicly held organization.
(B) The names of all holders of bonds or notes in excess of one
hundred thousand dollars ($100,000), if any.
(C) The names of all corporations and organizations that the
independent medical review organization controls or is affiliated
with, and the nature and extent of any ownership or control,
including the affiliated organization's type of business.
(D) The names and biographical sketches of all directors,
officers, and executives of the independent medical review
organization, as well as a statement regarding any past or present
relationships the directors, officers, and executives may have with
any health care service plan, disability insurer, managed care
organization, provider group, or board or committee of a plan,
managed care organization, or provider group.
(E) (i) The percentage of revenue the independent medical review
organization receives from expert reviews, including, but not limited
to, external medical reviews, quality assurance reviews, and
utilization reviews.
(ii) The names of any health care service plan or provider group
for which the independent medical review organization provides review
services, including, but not limited to, utilization review, quality
assurance review, and external medical review. Any change in this
information shall be reported to the department within five business
days of the change.
(F) A description of the review process including, but not limited
to, the method of selecting expert reviewers and matching the expert
reviewers to specific cases.
(G) A description of the system the independent medical review
organization uses to identify and recruit medical professionals to
review treatment and treatment recommendation decisions, the number
of medical professionals credentialed, and the types of cases and
areas of expertise that the medical professionals are credentialed to
review.
(H) A description of how the independent medical review
organization ensures compliance with the conflict-of-interest
provisions of this section.
(3) The organization shall demonstrate that it has a quality
assurance mechanism in place that does the following:
(A) Ensures that the medical professionals retained are
appropriately credentialed and privileged.
(B) Ensures that the reviews provided by the medical professionals
are timely, clear, and credible, and that reviews are monitored for
quality on an ongoing basis.
(C) Ensures that the method of selecting medical professionals for
individual cases achieves a fair and impartial panel of medical
professionals who are qualified to render recommendations regarding
the clinical conditions and the medical necessity of treatments or
therapies in question.
(D) Ensures the confidentiality of medical records and the review
materials, consistent with the requirements of this section and
applicable state and federal law.
(E) Ensures the independence of the medical professionals retained
to perform the reviews through conflict-of-interest policies and
prohibitions, and ensures adequate screening for
conflicts-of-interest, pursuant to paragraph (5).
(4) Medical professionals selected by independent medical review
organizations to review medical treatment decisions shall be
physicians or other appropriate providers who meet the following
minimum requirements:
(A) The medical professional shall be a clinician
knowledgeable expert in the treatment of the
enrollee's medical condition , and
knowledgeable about the proposed treatment , and familiar
with guidelines and protocols in the area of treatment under review
through recent or current actual clinical experience
treating patients with the same or a similar medical condition as the
enrollee .
(B) Notwithstanding any other provision of law, the medical
professional shall hold a nonrestricted license in any state of the
United States, and for physicians, a current certification by a
recognized American medical specialty board in the area or areas
appropriate to the condition or treatment under review. The
independent medical review organization shall give preference to the
use of a physician licensed in California as the reviewer, except
when training and experience with the issue under review reasonably
requires the use of an out-of-state reviewer.
(C) The medical professional shall have no history of disciplinary
action or sanctions, including, but not limited to, loss of staff
privileges or participation restrictions, taken or pending by any
hospital, government, or regulatory body.
(5) Neither the expert reviewer, nor the independent medical
review organization, shall have any material professional, material
familial, or material financial affiliation with any of the
following:
(A) The plan or a provider group of the plan, except that an
academic medical center under contract to the plan to provide
services to enrollees may qualify as an independent medical review
organization provided it will not provide the service and provided
the center is not the developer or manufacturer of the proposed
treatment.
(B) Any officer, director, or management employee of the plan.
(C) The physician, the physician's medical group, or the
independent practice association (IPA) proposing the treatment.
(D) The institution at which the treatment would be provided.
(E) The development or manufacture of the treatment proposed for
the enrollee whose condition is under review.
(F) The enrollee or the enrollee's immediate family.
(6) For purposes of this section, the following terms shall have
the following meanings:
(A) "Material familial affiliation" means any relationship as a
spouse, child, parent, sibling, spouse's parent, or child's spouse.
(B) "Material professional affiliation" means any
physician-patient relationship, any partnership or employment
relationship, a shareholder or similar ownership interest in a
professional corporation, or any independent contractor arrangement
that constitutes a material financial affiliation with any expert or
any officer or director of the independent medical review
organization. "Material professional affiliation" does not include
affiliations that are limited to staff privileges at a health
facility.
(C) "Material financial affiliation" means any financial interest
of more than 5 percent of total annual revenue or total annual income
of an independent medical review organization or individual to which
this subdivision applies. "Material financial affiliation" does not
include payment by the plan to the independent medical review
organization for the services required by this section, nor does
"material financial affiliation" include an expert's participation as
a contracting plan provider where the expert is affiliated with an
academic medical center or a National Cancer Institute-designated
clinical cancer research center.
(e) The department shall provide, upon the request of any
interested person, a copy of all nonproprietary information, as
determined by the director, filed with it by an independent medical
review organization seeking to contract under this article. The
department may charge a nominal fee to the interested person for
photocopying the requested information.
SEC. 2. Section 1374.33 of the Health and Safety Code is amended
to read:
1374.33. (a) Upon receipt of information and documents related to
a case, the medical professional reviewer or reviewers selected to
conduct the review by the independent medical review organization
shall promptly review all pertinent medical records of the enrollee,
provider reports, as well as any other information submitted to the
organization as authorized by the department or requested from any of
the parties to the dispute by the reviewers. If reviewers request
information from any of the parties, a copy of the request and the
response shall be provided to all of the parties. The reviewer or
reviewers shall also review relevant information related to the
criteria set forth in subdivision (b).
(b) Following its review, the reviewer or reviewers shall
determine whether the disputed health care service was medically
necessary based on the specific medical needs of the enrollee and any
of the following:
(1) Peer-reviewed scientific and medical evidence regarding the
effectiveness of the disputed service.
(2) Nationally recognized professional standards.
(3) Expert opinion.
(4) Generally accepted standards of medical practice.
(5) Treatments that are likely to provide a benefit to a patient
for conditions for which other treatments are not clinically
efficacious.
(c) The organization shall complete its review and make its
determination in writing, and in layperson's terms to the maximum
extent practicable, within 30 days of the receipt of the application
for review and supporting documentation, or within less time as
prescribed by the director. If the disputed health care service has
not been provided and the enrollee's provider or the department
certifies in writing that an imminent and serious threat to the
health of the enrollee may exist, including, but not limited to,
serious pain, the potential loss of life, limb, or major bodily
function, or the immediate and serious deterioration of the health of
the enrollee, the analyses and determinations of the reviewers shall
be expedited and rendered within three days of the receipt of the
information. Subject to the approval of the department, the deadlines
for analyses and determinations involving both regular and expedited
reviews may be extended by the director for up to three days in
extraordinary circumstances or for good cause.
(d) The medical professionals' analyses and determinations shall
state whether the disputed health care service is medically
necessary. Each analysis shall cite the enrollee's medical condition,
the relevant documents in the record, and the relevant findings
associated with the provisions of subdivision (b) to support the
determination. If more than one medical professional reviews the
case, the recommendation of the majority shall prevail. If the
medical professionals reviewing the case are evenly split as to
whether the disputed health care service should be provided, the
decision shall be in favor of providing the service.
(e) The independent medical review organization shall provide the
director, the plan, the enrollee, and the enrollee's provider with
the analyses and determinations of the medical professionals
reviewing the case, and a description of the qualifications of the
medical professionals. The independent medical review organization
shall keep the names of the reviewers confidential in all
communications with entities or individuals outside the independent
medical review organization, except in cases where the reviewer is
called to testify and in response to court orders. If more than one
medical professional reviewed the case and the result was differing
determinations, the independent medical review organization shall
provide each of the separate reviewer's analyses and determinations.
(f) The director shall immediately adopt the determination of the
independent medical review organization, and shall promptly issue a
written decision to the parties that shall be binding on the plan.
(g) After removing the names name of
the parties, including, but not limited to, the
enrollee, the names of all medical providers, the
plan, and any of the insurer's the names of the
health care service plan's employees or contractors, and
the name of any other party, other than the plan, director
decisions adopting a determination of an independent medical review
organization shall be made available by the department to the public
upon request, at the department's cost and on
the department's Internet Web site, after considering
applicable laws governing disclosure of public records,
confidentiality, and personal privacy. Pursuant to this
requirement, the department shall consult with and coordinate with
the Department of Insurance in the planning and
implementation of a common, searchable database that contains
information about each director and Insurance Commissioner decision
pursuant to subdivision (h).
(h) (1) Information regarding each director and commissioner
decision provided by the database referenced in subdivision (g) shall
include all of the following:
(A) Enrollee or insured demographic profile information, including
age, gender, and ethnicity.
(B) The department that contracted the independent medical review
organization that made the determination.
(C) Length of time to complete the independent medical review.
(D) Credentials and qualifications of the reviewer.
(E) The nature of the statutory criteria set forth in subdivision
(b) that the reviewer used to make the case decision.
(F) A detailed case summary that includes the specific standards,
criteria, and medical and scientific evidence, if any, that led to
the case decision.
(2) The database referenced in subdivision (g) shall also include
both of the following:
(A) The annual rate of independent medical review among the total
insured population.
(B) The number, type, and resolution of independent medical review
cases by health plan.
SEC. 3. Section 10169.2 of the Insurance Code is amended to read:
10169.2. (a) By January 1, 2001, the The
department shall contract with one or more independent medical
review organizations in the state to conduct reviews for purposes of
this article. The independent medical review organizations shall be
independent of any disability insurer doing business in this state.
The commissioner may establish additional requirements, including
conflict-of-interest standards, consistent with the purposes of this
article, that an organization shall be required to meet in order to
qualify for participation in the Independent Medical Review System
and to assist the department in carrying out its responsibilities.
(b) The independent medical review organizations and the medical
professionals retained to conduct reviews shall be deemed to be
medical consultants for purposes of Section 43.98 of the Civil Code.
(c) The independent medical review organization, any experts it
designates to conduct a review, or any officer, director, or employee
of the independent medical review organization shall not have any
material professional, familial, or financial affiliation, as
determined by the commissioner, with any of the following:
(1) The insurer.
(2) Any officer, director, or employee of the insurer.
(3) A physician, the physician's medical group, or the independent
practice association involved in the health care service in dispute.
(4) The facility or institution at which either the proposed
health care service, or the alternative service, if any, recommended
by the insurer, would be provided.
(5) The development or manufacture of the principal drug, device,
procedure, or other therapy proposed by the insured whose treatment
is under review, or the alternative therapy, if any, recommended by
the insurer.
(6) The insured or the insured's immediate family.
(d) In order to contract with the department for purposes of this
article, an independent medical review organization shall meet all of
the following requirements:
(1) The organization shall not be an affiliate or a subsidiary of,
nor in any way be owned or controlled by, a disability insurer or a
trade association of insurers. A board member, director, officer, or
employee of the independent medical review organization shall not
serve as a board member, director, or employee of a disability
insurer. A board member, director, or officer of a disability insurer
or a trade association of insurers shall not serve as a board
member, director, officer, or employee of an independent medical
review organization.
(2) The organization shall submit to the department the following
information upon initial application to contract for purposes of this
article and, except as otherwise provided, annually thereafter upon
any change to any of the following information:
(A) The names of all stockholders and owners of more than 5
percent of any stock or options, if a publicly held organization.
(B) The names of all holders of bonds or notes in excess of one
hundred thousand dollars ($100,000), if any.
(C) The names of all corporations and organizations that the
independent medical review organization controls or is affiliated
with, and the nature and extent of any ownership or control,
including the affiliated organization's type of business.
(D) The names and biographical sketches of all directors,
officers, and executives of the independent medical review
organization, as well as a statement regarding any past or present
relationships the directors, officers, and executives may have with
any health care service plan, disability insurer, managed care
organization, provider group, or board or committee of an insurer, a
plan, a managed care organization, or a provider group.
(E) (i) The percentage of revenue the independent medical review
organization receives from expert reviews, including, but not limited
to, external medical reviews, quality assurance reviews, and
utilization reviews.
(ii) The names of any insurer or provider group for which the
independent medical review organization provides review services,
including, but not limited to, utilization review, quality assurance
review, and external medical review. Any change in this information
shall be reported to the department within five business days of the
change.
(F) A description of the review process including, but not limited
to, the method of selecting expert reviewers and matching the expert
reviewers to specific cases.
(G) A description of the system the independent medical review
organization uses to identify and recruit medical professionals to
review treatment and treatment recommendation decisions, the number
of medical professionals credentialed, and the types of cases and
areas of expertise that the medical professionals are credentialed to
review.
(H) A description of how the independent medical review
organization ensures compliance with the conflict-of-interest
provisions of this section.
(3) The organization shall demonstrate that it has a quality
assurance mechanism in place that does the following:
(A) Ensures that the medical professionals retained are
appropriately credentialed and privileged.
(B) Ensures that the reviews provided by the medical professionals
are timely, clear, and credible, and that reviews are monitored for
quality on an ongoing basis.
(C) Ensures that the method of selecting medical professionals for
individual cases achieves a fair and impartial panel of medical
professionals who are qualified to render recommendations regarding
the clinical conditions and the medical necessity of treatments or
therapies in question.
(D) Ensures the confidentiality of medical records and the review
materials, consistent with the requirements of this section and
applicable state and federal law.
(E) Ensures the independence of the medical professionals retained
to perform the reviews through conflict-of-interest policies and
prohibitions, and ensures adequate screening for
conflicts-of-interest, pursuant to paragraph (5).
(4) Medical professionals selected by independent medical review
organizations to review medical treatment decisions shall be
physicians or other appropriate providers who meet the following
minimum requirements:
(A) The medical professional shall be a clinician
knowledgeable expert in the treatment of the
insured's medical condition , and
knowledgeable about the proposed treatment , and familiar
with guidelines and protocols in the area of treatment under review
through recent or current actual clinical experience
treating patients with the same or a similar medical condition as the
insured .
(B) Notwithstanding any other provision of law, the medical
professional shall hold a nonrestricted license in the any state of
the United States, and for physicians, a current certification by a
recognized American medical specialty board in the area or areas
appropriate to the condition or treatment under review. The
independent medical review organization shall give preference to the
use of a physician licensed in California as the reviewer, except
when training and experience with the issue under review reasonably
requires the use of an out-of-state reviewer.
(C) The medical professional shall have no history of disciplinary
action or sanctions, including, but not limited to, loss of staff
privileges or participation restrictions, taken or pending by any
hospital, government, or regulatory body.
(5) Neither the expert reviewer, nor the independent medical
review organization, shall have any material professional, material
familial, or material financial affiliation with any of the
following:
(A) The disability insurer or a provider group of the insurer,
except that an academic medical center under contract to the insurer
to provide services to insureds may qualify as an independent medical
review organization provided it will not provide the service and
provided the center is not the developer or manufacturer of the
proposed treatment.
(B) Any officer, director, or management employee of the insurer.
(C) The physician, the physician's medical group, or the
independent practice association (IPA) proposing the treatment.
(D) The institution at which the treatment would be provided.
(E) The development or manufacture of the treatment proposed for
the insured whose condition is under review.
(F) The insured or the insured's immediate family.
(6) For purposes of this section, the following terms shall have
the following meanings:
(A) "Material familial affiliation" means any relationship as a
spouse, child, parent, sibling, spouse's parent, or child's spouse.
(B) "Material professional affiliation" means any
physician-patient relationship, any partnership or employment
relationship, a shareholder or similar ownership interest in a
professional corporation, or any independent contractor arrangement
that constitutes a material financial affiliation with any expert or
any officer or director of the independent medical review
organization. "Material professional affiliation" does not include
affiliations that are limited to staff privileges at a health
facility.
(C) "Material financial affiliation" means any financial interest
of more than 5 percent of total annual revenue or total annual income
of an independent medical review organization or individual to which
this subdivision applies. "Material financial affiliation" does not
include payment by the insurer to the independent medical review
organization for the services required by this section, nor does
"material financial affiliation" include an expert's participation as
a contracting provider where the expert is affiliated with an
academic medical center or a National Cancer Institute-designated
clinical cancer research center.
(e) The department shall provide, upon the request of any
interested person, a copy of all nonproprietary information, as
determined by the commissioner, filed with it by an independent
medical review organization seeking to contract under this article.
The department may charge a nominal fee to the
interested person for photocopying the
requested information.
(f) The commissioner may contract with the Department of Managed
Health Care to administer the independent medical review process
established by this article.
SEC. 4. Section 10169.3 of the Insurance Code is amended to read:
10169.3. (a) Upon receipt of information and documents related to
a case, the medical professional reviewer or reviewers selected to
conduct the review by the independent medical review organization
shall promptly review all pertinent medical records of the insured,
provider reports, as well as any other information submitted to the
organization as authorized by the department or requested from any of
the parties to the dispute by the reviewers. If reviewers request
information from any of the parties, a copy of the request and the
response shall be provided to all of the parties. The reviewer or
reviewers shall also review relevant information related to the
criteria set forth in subdivision (b).
(b) Following its review, the reviewer or reviewers shall
determine whether the disputed health care service was medically
necessary based on the specific medical needs of the insured and any
of the following:
(A) Peer-reviewed scientific and medical evidence regarding the
effectiveness of the disputed service.
(B) Nationally recognized professional standards.
(C) Expert opinion.
(D) Generally accepted standards of medical practice.
(E) Treatments that are likely to provide a benefit to a patient
for conditions for which other treatments are not clinically
efficacious.
(c) The organization shall complete its review and make its
determination in writing, and in layperson's terms to the maximum
extent practicable, within 30 days of the receipt of the application
for review and supporting documentation, or within less time as
prescribed by the commissioner. If the disputed health care service
has not been provided and the insured's provider or the department
certifies in writing that an imminent and serious threat to the
health of the insured may exist, including, but not limited to,
serious pain, the potential loss of life, limb, or major bodily
function, or the immediate and serious deterioration of the health of
the insured, the analyses and determinations of the reviewers shall
be expedited and rendered within three days of the receipt of the
information. Subject to the approval of the department, the deadlines
for analyses and determinations involving both regular and expedited
reviews may be extended by the commissioner for up to three days in
extraordinary circumstances or for good cause.
(d) The medical professionals' analyses and determinations shall
state whether the disputed health care service is medically
necessary. Each analysis shall cite the insured's medical condition,
the relevant documents in the record, and the relevant findings
associated with the provisions of subdivision (b) to support the
determination. If more than one medical professional reviews the
case, the recommendation of the majority shall prevail. If the
medical professionals reviewing the case are evenly split as to
whether the disputed health care service should be provided, the
decision shall be in favor of providing the service.
(e) The independent medical review organization shall provide the
director, the insurer, the insured, and the insured's provider with
the analyses and determinations of the medical professionals
reviewing the case, and a description of the qualifications of the
medical professionals. The independent medical review organization
shall keep the names of the reviewers confidential in all
communications with entities or individuals outside the independent
medical review organization, except in cases where the reviewer is
called to testify and in response to court orders. If more than one
medical professional reviewed the case and the result was differing
determinations, the independent medical review organization shall
provide each of the separate reviewer's analyses and determinations.
(f) The commissioner shall immediately adopt the determination of
the independent medical review organization, and shall promptly issue
a written decision to the parties that shall be binding on the
insurer.
(g) After removing the names name of
the parties, including, but not limited to, the
insured, the names of all medical providers, the
insurer, and any names of the insurer's employees
or contractors, and the name of any other party, other than the
health plan, commissioner decisions adopting a determination
of an independent medical review organization shall be made available
by the department to the public upon request, at the
department's cost and on the department's Internet Web
site, after considering applicable laws governing disclosure
of public records, confidentiality, and personal privacy.
Pursuant to this requirement, the department shall consult with and
coordinate with the Department of Managed Health Care in the planning
and implementation of a common, searchable database that
contains information about each commissioner and Director of Managed
Health Care decision pursuant to subdivision (h).
(h) (1) Information regarding each commissioner and director
decision provided by the database referenced in subdivision (g) shall
include all of the following:
(A) Insured or enrollee demographic profile information, including
age, gender, and ethnicity.
(B) The department that contracted the independent medical review
organization that made the determination.
(C) Length of time to complete the independent medical review.
(D) Credentials and qualifications of the reviewer.
(E) The nature of the statutory criteria set forth in subdivision
(b) that the reviewer used to make the case decision.
(F) A detailed case summary that includes the specific standards,
criteria, and medical and scientific evidence, if any, that led to
the case decision.
(2) The database referenced in subdivision (g) shall also include
both of the following:
(A) The annual rate of independent medical review among the total
insured population.
(B) The number, type, and resolution of independent medical review
cases by health plan.
