1. (2) For an adverse benefit determination that is subject to subdivision (a)(1) of Section 2562.03, appropriate training and relevant experience in addiction care shall include active clinical practice in the treatment of patients with substance use disorders at the level of care or service intensity that is under review. An adverse benefit determination involving ASAM levels of care two through four, or as those service intensities are described in the most recent version of “The ASAM Criteria,” shall be made by, or in consultation with, an actively practicing board-certified addiction specialist physician.

2. (b) Pursuant to subdivision (h)(2) of Insurance Code section 10123.135, for utilization review coverage determinations involving urgent care services, including pursuant to a request by an insured, or an insured's authorized representative or provider, to extend an approved, ongoing course of treatment beyond the period of time or number of treatments that was previously approved, an insurer shall comply with the expedited review process that is required under Section 2719 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-19) and any subsequent regulations issued or incorporated thereunder, including Section 147.136 of Title 45 of the Code of Federal Regulations.

   1. (1) Any determination made by an insurer of whether medical or behavioral health care or treatment constitutes urgent care services shall defer to the opinion of an insured's attending health care provider. An insurer's negligence or fault in not requesting or reviewing records documenting such an opinion, or when an emergency medical condition or urgent care services were documented in an insured's medical record or supporting a submitted claim, shall not constitute the absence of an attending provider's opinion.
   2. (2) Subject to subdivision (i) of Section 2562.05, Insurance Code section 10123.191 and the regulations promulgated thereunder (Article 1.2 of Subchapter 2 of this chapter, commencing with Section 2218.30) shall govern a request for coverage of a prescription drug that is based on exigent circumstances as defined in that section or involves urgent care services as defined and used in this article. The preceding sentence does not limit the applicability of this article to prescription drugs.

3. (c) Except with respect to a denial or modification of a request for coverage of a prescription drug, an insurer shall include all the following content in a written notice of an adverse benefit determination that it provides to an insured, or an insured's authorized representative or provider, including the notices required by subdivision (h)(4) of Insurance Code section 10123.135 and notices of final adverse benefit determinations on appeal:

   1. (1) Information sufficient to identify the health care benefits and claim involved, including the health care benefits at issue, date of service, health care provider or facility, claim amount (if applicable), and a statement disclosing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning.
   2. (2) Reference to the location, and a description, of the applicable terms of the insured's coverage document.
   3. (3) A description of the specific clinical criteria that would be, or was, used to make the coverage determination, including a reference to the location of the criteria in the enclosure required by subdivision (d)(9) of this section.

   4. (4) The specific reasons for the adverse benefit determination.

      1. (A) If an adverse benefit determination was made due to insufficient information to make the determination, a description of the additional information that is reasonably necessary to make the coverage determination, and an explanation of why such information is necessary.
      2. (B) If an adverse benefit determination was made for a reason or reasons other than or in addition to insufficient information, a clear and concise explanation of the reasons for the adverse benefit determination, including explanation of how applying the relevant clinical criteria and terms of the insured's coverage document to the insured's individual circumstances supports the decision.
      3. (C) If an adverse benefit determination was made using one of the instruments required by Section 2562.03, the dimension component and combined scores on which the coverage determination was based.
   5. (5) A description of available internal appeals processes, including information regarding how to initiate an appeal. If an initial adverse benefit determination involved urgent care services, a description of the expedited review process for appeals involving urgent care services.
   6. (6) Notice of the availability of independent medical review and an enclosure (or attachment) of the Department's application for independent medical review.
   7. (7) Contact information for the Department's consumer assistance hotline and online consumer and provider complaint center, as provided at www.insurance.ca.gov.
   8. (8) In a written notice to an insured's health care provider, the name, title, direct phone number, email address, national provider identifier, and professional qualifications of the health care provider who made the adverse benefit determination.
   9. (9) An enclosure or attachment of the complete clinical criteria or guidelines used to make the adverse benefit determination. If the complete clinical criteria are available and accessible on an insurer's website, an insurer may instead provide the title of the applicable clinical policy and instructions for locating and accessing the clinical policy on the insurer's website and describe the process for obtaining a paper or electronic copy by email.
   10. (10) If an adverse benefit determination was made using the instruments required by Section 2562.03, or by applying clinical criteria developed by the World Professional Association for Transgender Health, notice of the availability of the formal education programs sponsored pursuant to Section 2562.08 and instructions for obtaining access to the training materials and resources as set forth in subdivision (b) of that section.
   11. (11) The nondiscrimination notice and taglines required by Insurance Code section 10133.11.

4. (d) Upon request of an insured or an insured's authorized representative for language assistance services in relation to a written notice of an adverse benefit determination, an insurer shall do the following:

   1. (1) Provide a written translation in an indicated language, as defined by Insurance Code section 10133.8 and Article 12.1 of Subchapter 3 of this chapter (commencing with Section 2538.1), or an applicable non-English language, within 21 calendar days of receiving a request therefor. With respect to an address in any county to which a notice is sent, a non-English language is an applicable non-English language if ten percent or more of the population residing in the county is literate only in the same non-English language.
   2. (2) For a request involving urgent care services, provide oral interpretation in an applicable non-English language during the same phone call, or for any other language, arrange for the insured or the insured's authorized representative to receive oral interpretation services in such person's preferred language free of charge within 24 hours of receiving the request.
5. (e) In the provision of written notices of adverse benefit determinations, an insurer shall comply with all laws governing the confidentiality and disclosure of personal information, including with respect to sensitive services under Insurance Code section 791.29.
6. (f) An insurer that authorized a health care benefit for a health condition, including but not limited to a mental health condition or substance use disorder, shall not rescind or modify the authorization after a health care provider or facility renders the health care benefit in good faith pursuant to that authorization for any reason, including, but not limited to, a subsequent rescission, cancellation, or modification of the insured's contract, a subsequent determination that the insurer did not make an accurate determination of the insured's eligibility for benefits or coverage, or pursuant to a concurrent or retrospective utilization review.

(a)(1) An adverse benefit determination shall be made only by a licensed physician or other licensed health care provider who is competent to evaluate the specific clinical issues involved in the health care benefits that are under review, meaning at a minimum, that the provider has appropriate training and relevant experience in the clinical specialty that is involved in the coverage determination, and the provider was trained if required by Section 2562.08.

Note: Authority cited: Sections 10123.135, 10133.8, 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 791.02, 796.04, 791.29, 10112.7, 10123.135, 10123.191, 10123.193, 10123.195, 10123.197, 10123.201, 10133.8, 10133.11, 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, 10144.57, 10145.3 and 10169, Insurance Code.

History

1. New section filed 6-26-2025; operative 6-26-2025 pursuant to Government Code section 11343.4(b)(3) (Register 2025, No. 26).