2001 REGULAR SESSION (71st) A AB422 335
Adoption of this amendment will MAINTAIN a 2/3s majority vote requirement for final passage of AB422 (§ 1).
ASSEMBLY ACTION Initial and Date |SENATE ACTION Initial and Date
Adopted Lost | Adopted Lost
Concurred In Not |Concurred In Not
Receded Not | Receded Not
Amend section 1, page 2, by deleting lines 6 through 36 and inserting:
“2. A certificate issued pursuant to this section expires 1 year after it is issued and may be renewed in accordance with regulations adopted by the commissioner.
3. Except as otherwise provided in subsection 6, before the commissioner may certify an external review organization, the external review organization must:
(a) Demonstrate to the satisfaction of the commissioner that it is able to carry out, in a timely manner, the duties of an external review organization set forth in this section and sections 4 to 12, inclusive, of this act. The demonstration must include, without limitation, proof that the external review organization employs, contracts with or otherwise retains only persons who are qualified because of their education, training, professional licensing and experience to perform the duties assigned to those persons; and
(b) Provide assurances satisfactory to the commissioner that the external review organization will:
(1) Conduct its external review activities in accordance with the provisions of this section and sections 4 to 12, inclusive, of this act;
(2) Provide its determinations in a clear, consistent, thorough and timely manner; and
(3) Avoid conflicts of interest.
4. For the purposes of this section, an external review organization has a conflict of interest if the external review organization or any employee, agent or contractor of the external review organization who conducts an external review has a material professional, familial or financial interest in any person who has a substantial interest in the outcome of the external review, including, without limitation:
(a) The insured;
(b) The insurer or any officer, director or management employee of the insurer;
(c) The provider of health care services that are provided or proposed to be provided, his partner or any other member of his medical group or practice;
(d) The hospital or other licensed health care facility where the health care service or treatment that is subject to external review has been or will be provided; or
(e) A developer, manufacturer or other person who has a substantial interest in the principal procedure, equipment, drug, device or other instrumentality that is the subject of the external review.
5. The commissioner shall not certify an external review organization that is affiliated with:
(a) A health care plan; or
(b) A national, state or local trade association.
6. An external review organization that is certified or accredited by an accrediting body that is nationally recognized shall be deemed to have satisfied all the conditions and qualifications required for certification pursuant to this section.”.
Amend section 1, page 2, line 37, by deleting “6.” and inserting “7.”.
Amend section 1, page 2, line 41, by deleting “7.” and inserting “8.”.
Amend section 1, pages 2 and 3, by deleting lines 46 through 48 on page 2 and lines 1 through 4 on page 3, and inserting:
“9. As used in this section:
(a) “External review organization” has the meaning ascribed to it in section 6 of this act.
(b) “Final adverse determination” has the meaning ascribed to it in section 7 of this act.
(c) “Provider of health care” means any physician or other person who is licensed, certified or otherwise authorized in this state or any other state to provide any health care service.”.
Amend sec. 5, page 3, by deleting lines 20 through 23 and inserting:
“1. Engaged in the practice of medicine; and
2. Certified or is eligible for certification by the board of medical”.
Amend sec. 7, page 3, by deleting lines 38 through 43 and inserting:
“1. Not medically necessary; or
2. Experimental or investigational.”.
Amend the bill as a whole by deleting sec. 8 and adding a new section designated sec. 8, following sec. 7, to read as follows:
“Sec. 8. “Medically necessary” means health care services or products that a prudent physician would provide to a patient to prevent, diagnose or treat an illness, injury or disease or any symptoms thereof that are:
1. Provided in accordance with generally accepted standards of medical practice;
2. Clinically appropriate with regard to type, frequency, extent, location and duration; and
3. Not primarily provided for the convenience of the patient, physician or other provider of health care.”.
Amend sec. 9, page 4, line 6, by deleting “90” and inserting “60”.
Amend sec. 9, page 4, by deleting lines 9 through 15 and inserting:
“2. Within 5 days after receiving a request pursuant to subsection 1, the managed care organization shall notify the insured, his authorized representative or his physician, the agent who performed utilization review for the managed care organization, if any, and the office for consumer health assistance that the request has been filed with the managed care organization.
3. Within 5 days after receiving a notification pursuant to subsection 2, the office for consumer health assistance shall:
(a) Randomly select an external review organization to conduct an external review of the final adverse determination;
(b) Notify the external review organization that it has been selected to conduct the external review; and
(c) Notify the insured, his authorized representative or his physician, the agent who performed utilization review for the managed care organization, if any, and the managed care organization of the external review organization selected to conduct the external review.
4. Upon notification by the office for consumer health assistance of the external review organization selected pursuant to subsection 3, the managed care organization shall provide to the external review organization all documents and”.
Amend sec. 9, page 4, line 18, by deleting “(1)” and inserting “(a)”.
Amend sec. 9, page 4, line 20, by deleting “(2)” and inserting “(b)”.
Amend sec. 9, page 4, line 22, by deleting “(3)” and inserting “(c)”.
Amend sec. 9, page 4, line 24, by deleting “(4)” and inserting “(d)”.
Amend sec. 9, page 4, line 25, by deleting “(5)” and inserting “(e)”.
Amend sec. 10, page 4, by deleting lines 39 through 41 and inserting:
“make that determination pursuant to this section. The external review organization shall submit a”.
Amend sec. 10, pages 4 and 5, by deleting lines 48 and 49 on page 4 and lines 1 through 14 on page 5, and inserting:
“3. A managed care organization shall approve or deny a request for an external review of a final adverse determination in an expedited manner not later than 72 hours after it receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured.
4. In making a determination pursuant to this section, an external”.
Amend sec. 11, page 5, by deleting lines 27 through 30 and inserting:
“Sec. 11. 1. The determination of an external review organization concerning an external review of a final adverse determination is final and binding upon the managed care organization.”.
Amend sec. 15, page 7, line 3, by deleting “and” and inserting “[and]”.
Amend sec. 15, page 7, by deleting lines 10 through 17 and inserting:
“determination if the managed care organization receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured, including notification of the procedure for requesting the expedited external review; and
(4) Receive assistance from any person, including an attorney, for an external review of a final adverse determination; and
(d) The telephone number of the office for consumer health assistance.”.
Amend sec. 16, page 8, by deleting lines 2 and 3 and inserting:
“regulations adopted by the commissioner of insurance, contract with at least two external review organizations that are certified by the commissioner of”.