AB 1048: Workers’ compensation.

Existing law establishes a workers compensation system, administered by the Administrative Director of the Division of Workers Compensation, to compensate an employee for injuries sustained in the course of employment. Existing law requires an employer to provide medical, surgical, chiropractic, acupuncture, and hospital treatment that is reasonably required to cure or relieve the injured worker from the effects of the injury. Upon payment, adjustment, or denial of a complete or incomplete itemization of medical services, existing law requires an employer to provide an explanation of review that includes, among other information, the amount paid and the basis for any adjustment, change, or denial of the item or procedure billed. Existing law requires every contracting agent, that sells, leases, assigns, transfers, or conveys its list of contract health care providers and their contracted reimbursement rates to a payor, to comply with certain requirements. Existing law also requires a payor to, among other things, provide an explanation of benefits or explanation of review that identifies the name of the network that the payor has an agreement with that entitles them to pay a preferred rate for the services rendered.

This bill would, when the basis for any adjustment, change, or denial of an item or procedure is a contract, would require the explanation of review or explanation of benefits to include information on that underlying contract, including whom the rendering medical provider may contact to seek a copy of the underlying contract. the state assigned medical provider network identification number and an email address that the rendering medical provider may use to request a copy of the underlying contract that entitles them to take the preferred rate. The bill would state that disclosure of a medical provider network does not satisfy this requirement and would state that if the contract is not sent to the rendering provider or their agent within 30 business days of the providers request, the bill shall be reprocessed and paid, as specified. requirement. The bill would require the payor, upon request, to provide the rendering provider or their agent with a copy of the underlying contract once per 365-day period.

Existing law requires each employer to establish a utilization review process to review and approve, modify, or deny treatment recommendations and establishes an independent medical review process to resolve disputes over a utilization review decision. Existing law requires various requirements to be met in determining whether to approve, modify, or deny requests by a physician for medical services.

This bill would require a request for authorization of medical services by a physician to be signed by that physician, and would authorize a request to be sent via mail, fax, or electronic methods, as specified. The bill would make other conforming changes.