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:
Here's my source, and a clip of what I was reading:
http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=01001-02000&file=1359-1366.4
Thank you!
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:
So I went to look this up myself and got a lot of jargon I didn't understand.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.
Here's my source, and a clip of what I was reading:
http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=01001-02000&file=1359-1366.4
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?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.
Thank you!
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