Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) For purposes of this section, the following
definitions shall apply:
(1) "Application For
Independent Medical Review" means a request for an independent medical review
received by the Department from an insured, covered person, or other
person.
(2) "Direct Department
Independent Medical Review System Costs" means the costs borne by the Department for
staff time and overhead in administering the Independent Medical Review System. This
administration includes the Department's activities in processing Applications For
Independent Medical Review submitted to the Department and the Department's
activities ensuring compliance with article 3.5 of division 2, part 2, chapter 1
commencing with section
10169 of the
Insurance Code when Health Requests For Assistance are received by the
Department.
(3) "Health Request For
Assistance" means a request for assistance received by the department from an
insured, covered person, or other person regarding an insurance policy which
provides coverage for hospital, medical, or surgical benefits.
(4) "Independent Medical Review Organization
Review Costs" means the fees charged by the independent medical review organization
for its medical reviews, as discussed in Insurance Code section
10169.5(a).
(5) "Independent Medical Review System" means the
system for reviewing insurance disputes described in Insurance Code section
10169.
(6) "Insurer" means every person holding a
certificate of authority and writing insurance subject to the Independent Medical
Review System described in Insurance Code section
10169.
(b) In addition to the assessment pursuant to
subdivision (d) of this section for Direct Department Independent Medical Review
System Costs, each Insurer shall pay all Independent Medical Review Organization
Review Costs directly to the independent medical review organization.
(c) Fees assessed and collected pursuant to this
section shall be deposited in the Insurance Fund for the purpose of funding the
Department's administration of the Independent Medical Review System.
(d) Each Insurer shall be assessed, and shall pay
as specified in this section, an annual fee, in the amount determined as specified
in this subdivision (d), as follows:
(1) The
Department each fiscal year shall adopt a total assessment equal to the expected
Direct Department Independent Medical Review System Costs for that year plus or
minus such amounts needed to maintain a reserve equal to 25 percent of the Direct
Department Independent Medical Review System Costs for that year as a contingency
against unanticipated fluctuations in Direct Department Independent Medical Review
System Costs and Independent Medical Review System fee assessment revenues and
expenditures.
(2) The total assessment
shall be apportioned among the various Insurers based on each Insurer's proportion
of the number of Health Requests For Assistance, Applications For Independent
Medical Review, and other similar requests or applications presented to the
Department by their insureds and covered persons pertaining to administration of the
Independent Medical Review System for the fiscal year previous to the fiscal year in
which the assessment is made, as compared to the total number of such requests and
applications presented to the department during the same period.
(3) The Department shall notify each Insurer of
the total assessment and the portion of the assessment required to be paid by that
Insurer each year by September 15. This notification will include the address for
payment and any other information necessary for such payment to be made. The Insurer
shall pay its share of the assessment within 45 days of the date of the notification
each year.
(e) If, at the end
of any fiscal year, the assessment results in the reserve being greater than the 25
percent reserve described in subdivision (d)(1) of this Section
2563, the Department shall take into
account the amount greater than the aforementioned 25 percent reserve in calculating
the assessment for the following fiscal year pursuant to subdivision (d)(1) of this
Section 2563.
1. New article
15.3 (section 2563) and section filed 5-26-2015; operative 7-1-2015 (Register 2015,
No. 22).
Note: Authority cited: Section
10169.5,
Insurance Code. Reference: Section
10169.5,
Insurance Code.
