BILL NUMBER: AB 2847	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 23, 2008
	AMENDED IN ASSEMBLY  MARCH 24, 2008
	AMENDED IN ASSEMBLY  MARCH 13, 2008

INTRODUCED BY   Assembly Member Krekorian
   (Principal coauthor: Assembly Member Huffman)

                        FEBRUARY 22, 2008

    An act to amend Section 1374.33 of, and to add Sections
1368.013 and 1374.37 to, the Health and Safety Code, and to add
Sections 10169.4 and 10169.6 to the Insurance Code,   An
act to amend Section 1374.30 of, and to add and repeal Section
1368.013 of, the Health and Safety Code, and to amend Section 10169
of, and to add and repeal Section 10169.4 of, the Insurance Code,
 relating to health care coverage.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 2847, as amended, Krekorian. Health care coverage.
   Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care. Existing law provides
for the regulation of health insurers by the Department of
Insurance. Existing law provides that a willful violation of
provisions governing health care service plans is a crime. Under
those laws, an enrollee or insured denied certain health care
services may appeal that denial through specified grievance and
medical review processes. 
    This 
    Until January 1, 2014, this  bill would require a plan
or insurer to disprove medical necessity  during any
grievance or medical review process   in any legal cause
of action that challenges   the plan's or insurer's
decision to deny, modify, or delay health care services, where the
treating provider has determined that the health care services were
medically necessary  , as specified. The bill would also allow a
treating provider to directly  appeal the denial of enrollee
or insured health care services   apply  to the
Department of Managed Health Care or Department of Insurance, as
applicable  , for an independent medical review of a decision to
deny, modify, or delay health care services to an enrollee,
subscriber, or insured, if the treating provider has received prior
consent from that enrollee, subscriber, or insured and that person
has exhausted any internal grievance process, as specified  .
   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 1368.013 is added to the Health and Safety
Code, to read:
   1368.013.   (a)    Notwithstanding any other
provision of law,  in any legal cause of action challenging a
plan's decision to deny, modify, or delay health care services, 
the plan has the burden of proof in any medical necessity
determination  or any determination to deny, reduce, limit,
or delay health care services, including, but not limited to, any
determination made pursuant to this article   where the
treating provider has determined that the   health care
services were medically necessary  . For purposes of this
section, "burden of proof" means that there shall be a presumption of
medical necessity, unless the plan proves otherwise in accordance
with the standard established in Section 115 of the Evidence Code.

   (b) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.  
  SEC. 2.    Section 1374.33 of the Health and
Safety Code is amended to read:
   1374.33.  (a)  (1) 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).
   (2) Notwithstanding any other provision of law, the plan has the
burden of proof in any medical review conducted pursuant to this
article. For purposes of this subdivision, "burden of proof" means
that there shall be a presumption of medical necessity, unless the
plan proves otherwise in accordance with the standard established in
Section 115 of the Evidence Code.
   (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 of the parties, including, but not
limited to, the enrollee, all medical providers, the plan, and any of
the insurer's employees or contractors, 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 after considering applicable laws governing
disclosure of public records, confidentiality, and personal privacy.
 
  SEC. 3.    Section 1374.37 is added to the Health
and Safety Code, to read:
   1374.37.  A treating provider may directly apply to the department
for an independent medical review of a decision to deny, modify, or
delay health care services with respect to a specific enrollee
pursuant to this article. 
   SEC. 2.    Section 1374.30 of the   Health
and Safety Code   is amended to read: 
   1374.30.  (a)  Commencing January 1, 2001, there is hereby
established in the department the Independent Medical Review System.
   (b) For the purposes of this chapter, "disputed health care
service" means any health care service eligible for coverage and
payment under a health care service plan contract that has been
denied, modified, or delayed by a decision of the plan, or by one of
its contracting providers, in whole or in part due to a finding that
the service is not medically necessary. A decision regarding a
disputed health care service relates to the practice of medicine and
is not a coverage decision. A disputed health care service does not
include services provided by a specialized health care service plan,
except to the extent that the service (1) involves the practice of
medicine, or (2) is provided pursuant to a contract with a health
care service plan that covers hospital, medical, or surgical
benefits. If a plan, or one of its contracting providers, issues a
decision denying, modifying, or delaying health care services, based
in whole or in part on a finding that the proposed health care
services are not a covered benefit under the contract that applies to
the enrollee, the statement of decision shall clearly specify the
provision in the contract that excludes that coverage.
   (c) For the purposes of this chapter, "coverage decision" means
the approval or denial of health care services by a plan, or by one
of its contracting entities, substantially based on a finding that
the provision of a particular service is included or excluded as a
covered benefit under the terms and conditions of the health care
service plan contract. A "coverage decision" does not encompass a
plan or contracting provider decision regarding a disputed health
care service.
   (d) (1) All enrollee grievances involving a disputed health care
service are eligible for review under the Independent Medical Review
System if the requirements of this article are met. If the department
finds that an enrollee grievance involving a disputed health care
service does not meet the requirements of this article for review
under the Independent Medical Review System, the enrollee request for
review shall be treated as a request for the department to review
the grievance pursuant to subdivision (b) of Section 1368. All other
enrollee grievances, including grievances involving coverage
decisions, remain eligible for review by the department pursuant to
subdivision (b) of Section 1368.
   (2) In any case in which an enrollee or provider asserts that a
decision to deny, modify, or delay health care services was based, in
whole or in part, on consideration of medical necessity, the
department shall have the final authority to determine whether the
grievance is more properly resolved pursuant to an independent
medical review as provided under this article or pursuant to
subdivision (b) of Section 1368.
   (3) The department shall be the final arbiter when there is a
question as to whether an enrollee grievance is a disputed health
care service or a coverage decision. The department shall establish a
process to complete an initial screening of an enrollee grievance.
If there appears to be any medical necessity issue, the grievance
shall be resolved pursuant to an independent medical review as
provided under this article or pursuant to subdivision (b) of Section
1368.
   (e) Every health care service plan contract that is issued,
amended, renewed, or delivered in this state on or after January 1,
2000, shall, effective January 1, 2001, provide an enrollee with the
opportunity to seek an independent medical review whenever health
care services have been denied, modified, or delayed by the plan, or
by one of its contracting providers, if the decision was based in
whole or in part on a finding that the proposed health care services
are not medically necessary. For purposes of this article, an
enrollee may designate an agent to act on his or her behalf, as
described in paragraph (2) of subdivision (b) of Section 1368.
 The provider may join with or otherwise assist the enrollee
in seeking an independent medical review, and may advocate on behalf
of the enrollee   A treating provider may direct 
 ly apply to the department for an independent medical review of
a decision to deny, modify, or delay health care services with
respect to a specific enrollee or subscriber, provided the treating
provider has obtained a written consent from the enrollee or
subscriber and the enrollee or subscriber has exhausted the internal
plan grievance system in Section 1368  .
   (f) Medi-Cal beneficiaries enrolled in a health care service plan
shall not be excluded from participation. Medicare beneficiaries
enrolled in a health care service plan shall not be excluded unless
expressly preempted by federal law. Reviews of cases for Medi-Cal
enrollees shall be conducted in accordance with statutes and
regulations for the Medi-Cal program.
   (g) The department may seek to integrate the quality of care and
consumer protection provisions, including remedies, of the
Independent Medical Review System with related dispute resolution
procedures of other health care agency programs, including the
Medicare and Medi-Cal programs, in a way that minimizes the potential
for duplication, conflict, and added costs. Nothing in this
subdivision shall be construed to limit any rights conferred upon
enrollees under this chapter.
   (h) The independent medical review process authorized by this
article is in addition to any other procedures or remedies that may
be available.
   (i) No later than January 1, 2001, every health care service plan
shall prominently display in every plan member handbook or relevant
informational brochure, in every plan contract, on enrollee evidence
of coverage forms, on copies of plan procedures for resolving
grievances, on letters of denials issued by either the plan or its
contracting organization, on the grievance forms required under
Section 1368, and on all written responses to grievances, information
concerning the right of an enrollee to request an independent
medical review in cases where the enrollee believes that health care
services have been improperly denied, modified, or delayed by the
plan, or by one of its contracting providers.
   (j) An enrollee may apply to the department for an independent
medical review when all of the following conditions are met:
   (1) (A) The enrollee's provider has recommended a health care
service as medically necessary, or
   (B) The enrollee has received urgent care or emergency services
that a provider determined was medically necessary, or
   (C) The enrollee, in the absence of a provider recommendation
under subparagraph (A) or the receipt of urgent care or emergency
services by a provider under subparagraph (B), has been seen by an
in-plan provider for the diagnosis or treatment of the medical
condition for which the enrollee seeks independent review. The plan
shall expedite access to an in-plan provider upon request of an
enrollee. The in-plan provider need not recommend the disputed health
care service as a condition for the enrollee to be eligible for an
independent review.
   For purposes of this article, the enrollee's provider may be an
out-of-plan provider. However, the plan shall have no liability for
payment of services provided by an out-of-plan provider, except as
provided pursuant to subdivision (c) of Section 1374.34.
   (2) The disputed health care service has been denied, modified, or
delayed by the plan, or by one of its contracting providers, based
in whole or in part on a decision that the health care service is not
medically necessary.
   (3) The enrollee has filed a grievance with the plan or its
contracting provider pursuant to Section 1368, and the disputed
decision is upheld or the grievance remains unresolved after 30 days.
The enrollee shall not be required to participate in the plan's
grievance process for more than 30 days. In the case of a grievance
that requires expedited review pursuant to Section 1368.01, the
enrollee shall not be required to participate in the plan's grievance
process for more than three days.
   (k) An enrollee may apply to the department for an independent
medical review of a decision to deny, modify, or delay health care
services, based in whole or in part on a finding that the disputed
health care services are not medically necessary, within six months
of any of the qualifying periods or events under subdivision (j). The
director may extend the application deadline beyond six months if
the circumstances of a case warrant the extension.
   (l) The enrollee shall pay no application or processing fees of
any kind.
   (m) As part of its notification to the enrollee regarding a
disposition of the enrollee's grievance that denies, modifies, or
delays health care services, the plan shall provide the enrollee with
a one-page application form approved by the department, and an
addressed envelope, which the enrollee may return to initiate an
independent medical review. The plan shall include on the form any
information required by the department to facilitate the completion
of the independent medical review, such as the enrollee's diagnosis
or condition, the nature of the disputed health care service sought
by the enrollee, a means to identify the enrollee's case, and any
other material information. The form shall also include the
following:
   (1) Notice that a decision not to participate in the independent
medical review process may cause the enrollee to forfeit any
statutory right to pursue legal action against the plan regarding the
disputed health care service.
   (2) A statement indicating the enrollee's consent to obtain any
necessary medical records from the plan, any of its contracting
providers, and any out-of-plan provider the enrollee may have
consulted on the matter, to be signed by the enrollee.
   (3) Notice of the enrollee's right to provide information or
documentation, either directly or through the enrollee's provider,
regarding any of the following:
   (A) A provider recommendation indicating that the disputed health
care service is medically necessary for the enrollee's medical
condition.
   (B) Medical information or justification that a disputed health
care service, on an urgent care or emergency basis, was medically
necessary for the enrollee's medical condition.
   (C) Reasonable information supporting the enrollee's position that
the disputed health care service is or was medically necessary for
the enrollee's medical condition, including all information provided
to the enrollee by the plan or any of its contracting providers,
still in the possession of the enrollee, concerning a plan or
provider decision regarding disputed health care services, and a copy
of any materials the enrollee submitted to the plan, still in the
possession of the enrollee, in support of the grievance, as well as
any additional material that the enrollee believes is relevant.
   (n) Upon notice from the department that the health care service
plan's enrollee has applied for an independent medical review, the
plan or its contracting providers shall provide to the independent
medical review organization designated by the department a copy of
all of the following documents within three business days of the plan'
s receipt of the department's notice of a request by an enrollee for
an independent review:
   (1) (A) A copy of all of the enrollee's medical records in the
possession of the plan or its contracting providers relevant to each
of the following:
   (i) The enrollee's medical condition.
   (ii) The health care services being provided by the plan and its
contracting providers for the condition.
   (iii) The disputed health care services requested by the enrollee
for the condition.
   (B) Any newly developed or discovered relevant medical records in
the possession of the plan or its contracting providers after the
initial documents are provided to the independent medical review
organization shall be forwarded immediately to the independent
medical review organization. The plan shall concurrently provide a
copy of medical records required by this subparagraph to the enrollee
or the enrollee's provider, if authorized by the enrollee, unless
the offer of medical records is declined or otherwise prohibited by
law. The confidentiality of all medical record information shall be
maintained pursuant to applicable state and federal laws.
   (2) A copy of all information provided to the enrollee by the plan
and any of its contracting providers concerning plan and provider
decisions regarding the enrollee's condition and care, and a copy of
any materials the enrollee or the enrollee's provider submitted to
the plan and to the plan's contracting providers in support of the
enrollee's request for disputed health care services. This
documentation shall include the written response to the enrollee's
grievance, required by paragraph (4) of subdivision (a) of Section
1368. The confidentiality of any enrollee medical information shall
be maintained pursuant to applicable state and federal laws.
   (3) A copy of any other relevant documents or information used by
the plan or its contracting providers in determining whether disputed
health care services should have been provided, and any statements
by the plan and its contracting providers explaining the reasons for
the decision to deny, modify, or delay disputed health care services
on the basis of medical necessity. The plan shall concurrently
provide a copy of documents required by this paragraph, except for
any information found by the director to be legally privileged
information, to the enrollee and the enrollee's provider. The
department and the independent review organization shall maintain the
confidentiality of any information found by the director to be the
proprietary information of the plan.
   SEC. 3.    Section 10169 of the   Insurance
Code   is amended to read: 
   10169.  (a) Commencing January 1, 2001, there is hereby
established in the department the Independent Medical Review System.
   (b) For the purposes of this chapter, "disputed health care
service" means any health care service eligible for coverage and
payment under a disability insurance contract that has been denied,
modified, or delayed by a decision of the insurer, or by one of its
contracting providers, in whole or in part due to a finding that the
service is not medically necessary. A decision regarding a disputed
health care service relates to the practice of medicine and is not a
coverage decision. A disputed health care service does not include
services provided by a group or individual policy of vision-only or
dental-only coverage, except to the extent that (1) the service
involves the practice of medicine, or (2) is provided pursuant to a
contract with a disability insurer that covers hospital, medical, or
surgical benefits. If an insurer, or one of its contracting
providers, issues a decision denying, modifying, or delaying health
care services, based in whole or in part on a finding that the
proposed health care services are not a covered benefit under the
contract that applies to the insured, the statement of decision shall
clearly specify the provision in the contract that excludes that
coverage.
   (c) For the purposes of this chapter, "coverage decision" means
the approval or denial of health care services by a disability
insurer, or by one of its contracting entities, substantially based
on a finding that the provision of a particular service is included
or excluded as a covered benefit under the terms and conditions of
the disability insurance contract. A coverage decision does not
encompass a disability insurer or contracting provider decision
regarding a disputed health care service.
   (d) (1) All insured grievances involving a disputed health care
service are eligible for review under the Independent Medical Review
System if the requirements of this article are met. If the department
finds that an insured grievance involving a disputed health care
service does not meet the requirements of this article for review
under the Independent Medical Review System, the insured request for
review shall be treated as a request for the department to review the
grievance. All other insured grievances, including grievances
involving coverage decisions, remain eligible for review by the
department.
   (2) In any case in which an insured or provider asserts that a
decision to deny, modify, or delay health care services was based, in
whole or in part, on consideration of medical necessity, the
department shall have the final authority to determine whether the
grievance is more properly resolved pursuant to an independent
medical review as provided under this article.
   (3) The department shall be the final arbiter when there is a
question as to whether an insured grievance is a disputed health care
service or a coverage decision. The department shall establish a
process to complete an initial screening of an insured grievance. If
there appears to be any medical necessity issue, the grievance shall
be resolved pursuant to an independent medical review as provided
under this article.
   (e) Every disability insurance contract that is issued, amended,
renewed, or delivered in this state on or after January 1, 2000,
shall, effective, January 1, 2001, provide an insured with the
opportunity to seek an independent medical review whenever health
care services have been denied, modified, or delayed by the insurer,
or by one of its contracting providers, if the decision was based in
whole or in part on a finding that the proposed health care services
are not medically necessary. For purposes of this article, an insured
may designate an agent to act on his or her behalf.  The
provider may join with or otherwise assist the insured in seeking an
independent medical review, and may advocate on behalf of the insured
  A treating provider may directly apply to the
department for an independent medical review of a decision to deny,
modify, or delay health care services with respect to a specific
insured, provided the treating provider has obtained a written
consent from the insured and the insured has exhausted the internal
insurer grievance system, if   any  .
   (f) Medicare beneficiaries enrolled in Medicare + Choice products
shall not be excluded unless expressly preempted by federal law.
   (g) The department may seek to integrate the quality of care and
consumer protection provisions, including remedies, of the
Independent Medical Review System with related dispute resolution
procedures of other health care agency programs, including the
Medicare program, in a way that minimizes the potential for
duplication, conflict, and added costs. Nothing in this subdivision
shall be construed to limit any rights conferred upon insureds under
this chapter.
   (h) The independent medical review process authorized by this
article is in addition to any other procedures or remedies that may
be available.
   (i) No later than January 1, 2001, every disability insurer shall
prominently display in every insurer member handbook or relevant
informational brochure, in every insurance contract, on insured
evidence of coverage forms, on copies of insurer procedures for
resolving grievances, on letters of denials issued by either the
insurer or its contracting organization, and on all written responses
to grievances,
information concerning the right of an insured to request an
independent medical review in cases where the insured believes that
health care services have been improperly denied, modified, or
delayed by the insurer, or by one of its contracting providers.
   (j) An insured may apply to the department for an independent
medical review when all of the following conditions are met:
   (1) (A) The insured's provider has recommended a health care
service as medically necessary, or
   (B) The insured has received urgent care or emergency services
that a provider determined was medically necessary, or
   (C) The insured, in the absence of a provider recommendation under
subparagraph (A) or the receipt of urgent care or emergency services
by a provider under subparagraph (B), has been seen by a contracting
provider for the diagnosis or treatment of the medical condition for
which the insured seeks independent review. The insurer shall
expedite access to a contracting provider upon request of an insured.
The contracting provider need not recommend the disputed health care
service as a condition for the insured to be eligible for an
independent review.
   For purposes of this article, the insured's provider may be a
noncontracting provider. However, the insurer shall have no liability
for payment of services provided by a noncontracting provider,
except as provided pursuant to Section 10169.3.
   (2) The disputed health care service has been denied, modified, or
delayed by the insurer, or by one of its contracting providers,
based in whole or in part on a decision that the health care service
is not medically necessary.
   (3) The insured has filed a grievance with the insurer or its
contracting provider, and the disputed decision is upheld or the
grievance remains unresolved after 30 days. The insured shall not be
required to participate in the insurer's grievance process for more
than 30 days. In the case of a grievance that requires expedited
review, the insured shall not be required to participate in the
insurer's grievance process for more than three days.
   (k) An insured may apply to the department for an independent
medical review of a decision to deny, modify, or delay health care
services, based in whole or in part on a finding that the disputed
health care services are not medically necessary, within six months
of any of the qualifying periods or events under subdivision (j). The
commissioner may extend the application deadline beyond six months
if the circumstances of a case warrant the extension.
   (l) The insured shall pay no application or processing fees of any
kind.
   (m) As part of its notification to the insured regarding a
disposition of the insured's grievance that denies, modifies, or
delays health care services, the insurer shall provide the insured
with a one-page application form approved by the department, and an
addressed envelope, which the insured may return to initiate an
independent medical review. The insurer shall include on the form any
information required by the department to facilitate the completion
of the independent medical review, such as the insured's diagnosis or
condition, the nature of the disputed health care service sought by
the insured, a means to identify the insured's case, and any other
material information. The form shall also include the following:
   (1) Notice that a decision not to participate in the independent
review process may cause the insured to forfeit any statutory right
to pursue legal action against the insurer regarding the disputed
health care service.
   (2) A statement indicating the insured's consent to obtain any
necessary medical records from the insurer, any of its contracting
providers, and any noncontracting provider the insured may have
consulted on the matter, to be signed by the insured.
   (3) Notice of the insured's right to provide information or
documentation, either directly or through the insured's provider,
regarding any of the following:
   (A) A provider recommendation indicating that the disputed health
care service is medically necessary for the insured's medical
condition.
   (B) Medical information or justification that a disputed health
care service, on an urgent care or emergency basis, was medically
necessary for the insured's medical condition.
   (C) Reasonable information supporting the insured's position that
the disputed health care service is or was medically necessary for
the insured's medical condition, including all information provided
to the insured by the insurer or any of its contracting providers,
still in the possession of the insured, concerning an insurer or
provider decision regarding disputed health care services, and a copy
of any materials the insured submitted to the insurer, still in the
possession of the insured, in support of the grievance, as well as
any additional material that the insured believes is relevant.
   (n) Upon notice from the department that the insured has applied
for an independent medical review, the insurer or its contracting
providers, shall provide to the independent medical review
organization designated by the department a copy of all of the
following documents within three business days of the insurer's
receipt of the department's notice of a request by an insured for an
independent review:
   (1) (A) A copy of all of the insured's medical records in the
possession of the insurer or its contracting providers relevant to
each of the following:
   (i) The insured's medical condition.
   (ii) The health care services being provided by the insurer and
its contracting providers for the condition.
   (iii) The disputed health care services requested by the insured
for the condition.
   (B) Any newly developed or discovered relevant medical records in
the possession of the insurer or its contracting providers after the
initial documents are provided to the independent medical review
organization shall be forwarded immediately to the independent
medical review organization. The insurer shall concurrently provide a
copy of medical records required by this subparagraph to the insured
or the insured's provider, if authorized by the insured, unless the
offer of medical records is declined or otherwise prohibited by law.
The confidentiality of all medical record information shall be
maintained pursuant to applicable state and federal laws.
   (2) A copy of all information provided to the insured by the
insurer and any of its contracting providers concerning insurer and
provider decisions regarding the insured's condition and care, and a
copy of any materials the insured or the insured's provider submitted
to the insurer and to the insurer's contracting providers in support
of the insured's request for disputed health care services. This
documentation shall include the written response to the insured's
grievance. The confidentiality of any insured medical information
shall be maintained pursuant to applicable state and federal laws.
   (3) A copy of any other relevant documents or information used by
the insurer or its contracting providers in determining whether
disputed health care services should have been provided, and any
statements by the insurer and its contracting providers explaining
the reasons for the decision to deny, modify, or delay disputed
health care services on the basis of medical necessity. The insurer
shall concurrently provide a copy of documents required by this
paragraph, except for any information found by the commissioner to be
legally privileged information, to the insured and the insured's
provider. The department and the independent review organization
shall maintain the confidentiality of any information found by the
commissioner to be the proprietary information of the insurer.
   SEC. 4.  Section 10169.4 is added to the Insurance Code, to read:
   10169.4.   (a)    Notwithstanding any other
provision of law,  in any legal cause of action challenging an
insurer's decision to deny, modify, or delay health care services,
 the insurer has the burden of proof in any medical necessity
 determination or any determination to deny, reduce, limit,
or delay health care services, including, but not limited to, any
determination made pursuant to this article  
determination where the treating provider has   determined
that the health care services were medically necessary  . For
purposes of this section, "burden of proof" means that there shall be
a presumption of medical necessity, unless the insurer proves
otherwise in accordance with the standard established in Section 115
of the Evidence Code. 
   (b) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.  
  SEC. 5.    Section 10169.6 is added to the
Insurance Code, to read:
   10169.6.  A treating provider may directly apply to the department
for an independent medical review of a decision to deny, modify, or
delay health care services with respect to a specific insured
pursuant to this article. 
                            ____ CORRECTIONS  Text-Page 2.
                                                   ____