The department shall conduct annual medical audits of each prepaid health plan unless the director determines there is good cause for additional reviews.
The reviews shall use the standards and criteria established pursuant to the Knox-Keene Health Care Service Plan Act of 1975, as appropriate. Except in those instances where major unanticipated administrative obstacles prevent, or after a determination by the director of good cause, the reviews shall be scheduled and carried out jointly with reviews carried out pursuant to the Knox-Keene Health Care Service Plan Act of 1975, if reviews will be carried out within time periods which satisfy the requirements of federal law.
The department shall be authorized to contract with professional organizations or the Department of Managed Health Care, as appropriate, to perform the periodic review required by this section. The department, or its designee, shall make a finding of fact with respect to the ability of the prepaid health plan to provide quality health care services, effectiveness of peer review, and utilization control mechanisms, and the overall performance of the prepaid health plan in providing health care benefits to its enrollees.
The director shall publicly report the findings of finalized annual medical audits conducted pursuant to this section as soon as possible, but no later than 90 days following completion of any corrective action plan initiated pursuant to the audit, if any, unless the director determines, in his or her discretion, that additional time is reasonably necessary to fully and fairly report the results of the audit.
(Amended by Stats. 2014, Ch. 573, Sec. 5. (SB 964) Effective January 1, 2015.)
Last modified: October 25, 2018