Fuzzy Wording

[gryndor]

What is the name of your state? California

I am researching a surgical procedure for which I must be pre-approved. However, the insurance company is rather tight-lipped when it comes to their criteria. I found a testimonial from another person and she said this:

They didnt give me the criteria until I pressed yet again and then quoted this to them: California Health & Safety Code section 1363.5 mandates access to these criteria including identification of the authors of the criteria, the clinical principles utilized to develop the criteria, the last time it was reviewed and updated, etc This time they miraculously found the criteria, and they were more certain of telling me all as I was upset.

So I went to look this up myself and got a lot of jargon I didn't understand.

Here's my source, and a clip of what I was reading:

[url]http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=01001-02000&file=1359-1366.4[/url]

1363.5. (a) A plan shall disclose or provide for the disclosure to the director and to network providers the process the plan, its contracting provider groups, or any entity with which the plan contracts for services that include utilization review or utilization management functions, uses to authorize, modify, or deny health care services under the benefits provided by the plan, including coverage for subacute care, transitional inpatient care, or care provided in skilled nursing facilities. A plan shall also disclose those processes to enrollees or persons designated by an enrollee, or to any other person or organization, upon request. The disclosure to the director shall include the policies, procedures, and the description of the process that are filed with the director pursuant to subdivision (b) of Section 1367.01.

Could someone please translate this into English for me? Was the lady from the testimonial correct? Or will I come off looking like an a$$ if I were to quote her blindly?

Thank you!

[gryndor]

Apparently Saturday evening was a bad time to post...

*bump*

[ellencee]

gryndor
It means they owe you an explanation of why they are denying coverage for the procedure. It also means their decision must be based on established policy and procedure, including a utilization review committee (specific standards exist for UR). It means they must not only tell your physician why the procedure is being denied but they must tell you and you and your physician must be provided with the written policies and procedures on which the denial was based.

EC