CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Assembly Bill No. 682Introduced by Assembly Member Ortega(Principal coauthor: Assembly Member Kalra)February 14, 2025 An act to amend Section 1384 of the Health and Safety Code, and to amend Section 10127.19 of the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 682, as introduced, Ortega. Health care coverage reporting. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law requires a plan to submit financial statements to the Director of Managed Health Care at specified times. Existing law provides for the regulation of health insurers by the Department of Insurance and requires a health insurer or multiple employer welfare arrangement to annually report specified information to the department.This bill would require the above-described reports to include specified information for each month, including the total number of claims processed, adjudicated, denied, or partially denied. Because a violation of this requirement by a health care service plan would be a crime, the bill would create a state-mandated local program. The bill would require each department to publish on its internet website monthly claims denial information for each plan or insurer.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1384 of the Health and Safety Code is amended to read:1384. (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report containing audited financial statements covering the 12-calendar months next preceding the month of receipt of the request, or another period as the director may require.(b) On or before 105 days after the date of a notice of surrender or order of revocation, a plan shall file with the director a closing audit report containing audited financial statements. The reporting period for the closing audit report shall be the 12-month period preceding the date of the notice of surrender or order of revocation, or for another period as the director may specify. This report shall include other relevant information as specified by rule of the director. The director shall not consent to a surrender and an order of revocation shall not be considered final until the closing audit report has been filed with the director and all concerns raised by the director therefrom have been resolved by the plan, as determined by the director. For good cause, the director may waive the requirement of a closing audit report.(c) Except as otherwise provided in this subdivision, each plan shall submit financial statements prepared as of the close of its fiscal year within 120 days after the close of the fiscal year. The financial statements referred to in this subdivision and in subdivisions (a) and (b) of this section shall be accompanied by a report, certificate, or opinion of an independent certified public accountant or independent public accountant. The audits shall be conducted in accordance with generally accepted auditing standards and the rules and regulations of the director. However, financial statements from public entities or political subdivisions of the state whose audits are conducted by a county grand jury shall be submitted within 180 days after the close of the fiscal year and need not include a report, certificate, or opinion by an independent certified public accountant or an independent public accountant, and the audit shall be conducted in accordance with governmental auditing standards.(d) (1) The financial statements required pursuant to subdivisions (a) to (c), inclusive, shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the director may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each plan in a manner prescribed by the director.(3) For the purposes of this subdivision:(A) Adjudicated means a plan or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 1367.01.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by a plan or other person subject to this chapter.(d)(e) A plan, solicitor, or solicitor firm shall make any special reports to the director as the director may from time to time require.(e)(f) For good cause and upon written request, the director may extend the time for compliance with subdivisions (a), (b), and (h) of this section. (i).(f)(g) A plan, solicitor, or solicitor firm shall, when requested by the director, for good cause, submit its unaudited financial statement, prepared in accordance with generally accepted accounting principles and consisting of at least a balance sheet and statement of income as of the date and for the period specified by the director. The director may require the submission of these reports on a monthly or other periodic basis.(g)(h) If the report, certificate, or opinion of the independent accountant referred to in subdivision (c) is in any way qualified, the director may require the plan to take any action as the director deems appropriate to permit an independent accountant to remove the qualification from the report, certificate, or opinion.(h)(i) The director may reject any financial statement, report, certificate, or opinion filed pursuant to this section by notifying the plan, solicitor, or solicitor firm required to make this filing of its rejection and the cause thereof. Within 30 days after the receipt of the notice, the person shall correct the deficiency, and the failure so to do shall be deemed a violation of this chapter. The director shall retain a copy of all filings so rejected.(i)(j) The director may make rules and regulations specifying the form and content of the reports and financial statements referred to in this section, and may require that these reports and financial statements be verified by the plan or other person subject to this chapter in a manner as the director may prescribe.SEC. 2. Section 10127.19 of the Insurance Code is amended to read:10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b).(b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows:(1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a).(2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision.(c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the departments internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year.(d) (1) The reports required pursuant to subdivisions (a) and (b) shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the department may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each insurer or MEWA in a manner prescribed by the commissioner.(3) For the purposes of this subdivision:(A) Adjudicated means an insurer, MEWA, or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 10123.135.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by an insurer, MEWA, or other person subject to this chapter.SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Assembly Bill No. 682Introduced by Assembly Member Ortega(Principal coauthor: Assembly Member Kalra)February 14, 2025 An act to amend Section 1384 of the Health and Safety Code, and to amend Section 10127.19 of the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 682, as introduced, Ortega. Health care coverage reporting. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law requires a plan to submit financial statements to the Director of Managed Health Care at specified times. Existing law provides for the regulation of health insurers by the Department of Insurance and requires a health insurer or multiple employer welfare arrangement to annually report specified information to the department.This bill would require the above-described reports to include specified information for each month, including the total number of claims processed, adjudicated, denied, or partially denied. Because a violation of this requirement by a health care service plan would be a crime, the bill would create a state-mandated local program. The bill would require each department to publish on its internet website monthly claims denial information for each plan or insurer.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES
CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION
Assembly Bill
No. 682
Introduced by Assembly Member Ortega(Principal coauthor: Assembly Member Kalra)February 14, 2025
Introduced by Assembly Member Ortega(Principal coauthor: Assembly Member Kalra)
February 14, 2025
An act to amend Section 1384 of the Health and Safety Code, and to amend Section 10127.19 of the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 682, as introduced, Ortega. Health care coverage reporting.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law requires a plan to submit financial statements to the Director of Managed Health Care at specified times. Existing law provides for the regulation of health insurers by the Department of Insurance and requires a health insurer or multiple employer welfare arrangement to annually report specified information to the department.This bill would require the above-described reports to include specified information for each month, including the total number of claims processed, adjudicated, denied, or partially denied. Because a violation of this requirement by a health care service plan would be a crime, the bill would create a state-mandated local program. The bill would require each department to publish on its internet website monthly claims denial information for each plan or insurer.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law requires a plan to submit financial statements to the Director of Managed Health Care at specified times. Existing law provides for the regulation of health insurers by the Department of Insurance and requires a health insurer or multiple employer welfare arrangement to annually report specified information to the department.
This bill would require the above-described reports to include specified information for each month, including the total number of claims processed, adjudicated, denied, or partially denied. Because a violation of this requirement by a health care service plan would be a crime, the bill would create a state-mandated local program. The bill would require each department to publish on its internet website monthly claims denial information for each plan or insurer.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 1384 of the Health and Safety Code is amended to read:1384. (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report containing audited financial statements covering the 12-calendar months next preceding the month of receipt of the request, or another period as the director may require.(b) On or before 105 days after the date of a notice of surrender or order of revocation, a plan shall file with the director a closing audit report containing audited financial statements. The reporting period for the closing audit report shall be the 12-month period preceding the date of the notice of surrender or order of revocation, or for another period as the director may specify. This report shall include other relevant information as specified by rule of the director. The director shall not consent to a surrender and an order of revocation shall not be considered final until the closing audit report has been filed with the director and all concerns raised by the director therefrom have been resolved by the plan, as determined by the director. For good cause, the director may waive the requirement of a closing audit report.(c) Except as otherwise provided in this subdivision, each plan shall submit financial statements prepared as of the close of its fiscal year within 120 days after the close of the fiscal year. The financial statements referred to in this subdivision and in subdivisions (a) and (b) of this section shall be accompanied by a report, certificate, or opinion of an independent certified public accountant or independent public accountant. The audits shall be conducted in accordance with generally accepted auditing standards and the rules and regulations of the director. However, financial statements from public entities or political subdivisions of the state whose audits are conducted by a county grand jury shall be submitted within 180 days after the close of the fiscal year and need not include a report, certificate, or opinion by an independent certified public accountant or an independent public accountant, and the audit shall be conducted in accordance with governmental auditing standards.(d) (1) The financial statements required pursuant to subdivisions (a) to (c), inclusive, shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the director may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each plan in a manner prescribed by the director.(3) For the purposes of this subdivision:(A) Adjudicated means a plan or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 1367.01.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by a plan or other person subject to this chapter.(d)(e) A plan, solicitor, or solicitor firm shall make any special reports to the director as the director may from time to time require.(e)(f) For good cause and upon written request, the director may extend the time for compliance with subdivisions (a), (b), and (h) of this section. (i).(f)(g) A plan, solicitor, or solicitor firm shall, when requested by the director, for good cause, submit its unaudited financial statement, prepared in accordance with generally accepted accounting principles and consisting of at least a balance sheet and statement of income as of the date and for the period specified by the director. The director may require the submission of these reports on a monthly or other periodic basis.(g)(h) If the report, certificate, or opinion of the independent accountant referred to in subdivision (c) is in any way qualified, the director may require the plan to take any action as the director deems appropriate to permit an independent accountant to remove the qualification from the report, certificate, or opinion.(h)(i) The director may reject any financial statement, report, certificate, or opinion filed pursuant to this section by notifying the plan, solicitor, or solicitor firm required to make this filing of its rejection and the cause thereof. Within 30 days after the receipt of the notice, the person shall correct the deficiency, and the failure so to do shall be deemed a violation of this chapter. The director shall retain a copy of all filings so rejected.(i)(j) The director may make rules and regulations specifying the form and content of the reports and financial statements referred to in this section, and may require that these reports and financial statements be verified by the plan or other person subject to this chapter in a manner as the director may prescribe.SEC. 2. Section 10127.19 of the Insurance Code is amended to read:10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b).(b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows:(1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a).(2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision.(c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the departments internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year.(d) (1) The reports required pursuant to subdivisions (a) and (b) shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the department may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each insurer or MEWA in a manner prescribed by the commissioner.(3) For the purposes of this subdivision:(A) Adjudicated means an insurer, MEWA, or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 10123.135.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by an insurer, MEWA, or other person subject to this chapter.SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 1384 of the Health and Safety Code is amended to read:1384. (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report containing audited financial statements covering the 12-calendar months next preceding the month of receipt of the request, or another period as the director may require.(b) On or before 105 days after the date of a notice of surrender or order of revocation, a plan shall file with the director a closing audit report containing audited financial statements. The reporting period for the closing audit report shall be the 12-month period preceding the date of the notice of surrender or order of revocation, or for another period as the director may specify. This report shall include other relevant information as specified by rule of the director. The director shall not consent to a surrender and an order of revocation shall not be considered final until the closing audit report has been filed with the director and all concerns raised by the director therefrom have been resolved by the plan, as determined by the director. For good cause, the director may waive the requirement of a closing audit report.(c) Except as otherwise provided in this subdivision, each plan shall submit financial statements prepared as of the close of its fiscal year within 120 days after the close of the fiscal year. The financial statements referred to in this subdivision and in subdivisions (a) and (b) of this section shall be accompanied by a report, certificate, or opinion of an independent certified public accountant or independent public accountant. The audits shall be conducted in accordance with generally accepted auditing standards and the rules and regulations of the director. However, financial statements from public entities or political subdivisions of the state whose audits are conducted by a county grand jury shall be submitted within 180 days after the close of the fiscal year and need not include a report, certificate, or opinion by an independent certified public accountant or an independent public accountant, and the audit shall be conducted in accordance with governmental auditing standards.(d) (1) The financial statements required pursuant to subdivisions (a) to (c), inclusive, shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the director may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each plan in a manner prescribed by the director.(3) For the purposes of this subdivision:(A) Adjudicated means a plan or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 1367.01.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by a plan or other person subject to this chapter.(d)(e) A plan, solicitor, or solicitor firm shall make any special reports to the director as the director may from time to time require.(e)(f) For good cause and upon written request, the director may extend the time for compliance with subdivisions (a), (b), and (h) of this section. (i).(f)(g) A plan, solicitor, or solicitor firm shall, when requested by the director, for good cause, submit its unaudited financial statement, prepared in accordance with generally accepted accounting principles and consisting of at least a balance sheet and statement of income as of the date and for the period specified by the director. The director may require the submission of these reports on a monthly or other periodic basis.(g)(h) If the report, certificate, or opinion of the independent accountant referred to in subdivision (c) is in any way qualified, the director may require the plan to take any action as the director deems appropriate to permit an independent accountant to remove the qualification from the report, certificate, or opinion.(h)(i) The director may reject any financial statement, report, certificate, or opinion filed pursuant to this section by notifying the plan, solicitor, or solicitor firm required to make this filing of its rejection and the cause thereof. Within 30 days after the receipt of the notice, the person shall correct the deficiency, and the failure so to do shall be deemed a violation of this chapter. The director shall retain a copy of all filings so rejected.(i)(j) The director may make rules and regulations specifying the form and content of the reports and financial statements referred to in this section, and may require that these reports and financial statements be verified by the plan or other person subject to this chapter in a manner as the director may prescribe.
SECTION 1. Section 1384 of the Health and Safety Code is amended to read:
### SECTION 1.
1384. (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report containing audited financial statements covering the 12-calendar months next preceding the month of receipt of the request, or another period as the director may require.(b) On or before 105 days after the date of a notice of surrender or order of revocation, a plan shall file with the director a closing audit report containing audited financial statements. The reporting period for the closing audit report shall be the 12-month period preceding the date of the notice of surrender or order of revocation, or for another period as the director may specify. This report shall include other relevant information as specified by rule of the director. The director shall not consent to a surrender and an order of revocation shall not be considered final until the closing audit report has been filed with the director and all concerns raised by the director therefrom have been resolved by the plan, as determined by the director. For good cause, the director may waive the requirement of a closing audit report.(c) Except as otherwise provided in this subdivision, each plan shall submit financial statements prepared as of the close of its fiscal year within 120 days after the close of the fiscal year. The financial statements referred to in this subdivision and in subdivisions (a) and (b) of this section shall be accompanied by a report, certificate, or opinion of an independent certified public accountant or independent public accountant. The audits shall be conducted in accordance with generally accepted auditing standards and the rules and regulations of the director. However, financial statements from public entities or political subdivisions of the state whose audits are conducted by a county grand jury shall be submitted within 180 days after the close of the fiscal year and need not include a report, certificate, or opinion by an independent certified public accountant or an independent public accountant, and the audit shall be conducted in accordance with governmental auditing standards.(d) (1) The financial statements required pursuant to subdivisions (a) to (c), inclusive, shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the director may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each plan in a manner prescribed by the director.(3) For the purposes of this subdivision:(A) Adjudicated means a plan or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 1367.01.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by a plan or other person subject to this chapter.(d)(e) A plan, solicitor, or solicitor firm shall make any special reports to the director as the director may from time to time require.(e)(f) For good cause and upon written request, the director may extend the time for compliance with subdivisions (a), (b), and (h) of this section. (i).(f)(g) A plan, solicitor, or solicitor firm shall, when requested by the director, for good cause, submit its unaudited financial statement, prepared in accordance with generally accepted accounting principles and consisting of at least a balance sheet and statement of income as of the date and for the period specified by the director. The director may require the submission of these reports on a monthly or other periodic basis.(g)(h) If the report, certificate, or opinion of the independent accountant referred to in subdivision (c) is in any way qualified, the director may require the plan to take any action as the director deems appropriate to permit an independent accountant to remove the qualification from the report, certificate, or opinion.(h)(i) The director may reject any financial statement, report, certificate, or opinion filed pursuant to this section by notifying the plan, solicitor, or solicitor firm required to make this filing of its rejection and the cause thereof. Within 30 days after the receipt of the notice, the person shall correct the deficiency, and the failure so to do shall be deemed a violation of this chapter. The director shall retain a copy of all filings so rejected.(i)(j) The director may make rules and regulations specifying the form and content of the reports and financial statements referred to in this section, and may require that these reports and financial statements be verified by the plan or other person subject to this chapter in a manner as the director may prescribe.
1384. (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report containing audited financial statements covering the 12-calendar months next preceding the month of receipt of the request, or another period as the director may require.(b) On or before 105 days after the date of a notice of surrender or order of revocation, a plan shall file with the director a closing audit report containing audited financial statements. The reporting period for the closing audit report shall be the 12-month period preceding the date of the notice of surrender or order of revocation, or for another period as the director may specify. This report shall include other relevant information as specified by rule of the director. The director shall not consent to a surrender and an order of revocation shall not be considered final until the closing audit report has been filed with the director and all concerns raised by the director therefrom have been resolved by the plan, as determined by the director. For good cause, the director may waive the requirement of a closing audit report.(c) Except as otherwise provided in this subdivision, each plan shall submit financial statements prepared as of the close of its fiscal year within 120 days after the close of the fiscal year. The financial statements referred to in this subdivision and in subdivisions (a) and (b) of this section shall be accompanied by a report, certificate, or opinion of an independent certified public accountant or independent public accountant. The audits shall be conducted in accordance with generally accepted auditing standards and the rules and regulations of the director. However, financial statements from public entities or political subdivisions of the state whose audits are conducted by a county grand jury shall be submitted within 180 days after the close of the fiscal year and need not include a report, certificate, or opinion by an independent certified public accountant or an independent public accountant, and the audit shall be conducted in accordance with governmental auditing standards.(d) (1) The financial statements required pursuant to subdivisions (a) to (c), inclusive, shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the director may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each plan in a manner prescribed by the director.(3) For the purposes of this subdivision:(A) Adjudicated means a plan or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 1367.01.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by a plan or other person subject to this chapter.(d)(e) A plan, solicitor, or solicitor firm shall make any special reports to the director as the director may from time to time require.(e)(f) For good cause and upon written request, the director may extend the time for compliance with subdivisions (a), (b), and (h) of this section. (i).(f)(g) A plan, solicitor, or solicitor firm shall, when requested by the director, for good cause, submit its unaudited financial statement, prepared in accordance with generally accepted accounting principles and consisting of at least a balance sheet and statement of income as of the date and for the period specified by the director. The director may require the submission of these reports on a monthly or other periodic basis.(g)(h) If the report, certificate, or opinion of the independent accountant referred to in subdivision (c) is in any way qualified, the director may require the plan to take any action as the director deems appropriate to permit an independent accountant to remove the qualification from the report, certificate, or opinion.(h)(i) The director may reject any financial statement, report, certificate, or opinion filed pursuant to this section by notifying the plan, solicitor, or solicitor firm required to make this filing of its rejection and the cause thereof. Within 30 days after the receipt of the notice, the person shall correct the deficiency, and the failure so to do shall be deemed a violation of this chapter. The director shall retain a copy of all filings so rejected.(i)(j) The director may make rules and regulations specifying the form and content of the reports and financial statements referred to in this section, and may require that these reports and financial statements be verified by the plan or other person subject to this chapter in a manner as the director may prescribe.
1384. (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report containing audited financial statements covering the 12-calendar months next preceding the month of receipt of the request, or another period as the director may require.(b) On or before 105 days after the date of a notice of surrender or order of revocation, a plan shall file with the director a closing audit report containing audited financial statements. The reporting period for the closing audit report shall be the 12-month period preceding the date of the notice of surrender or order of revocation, or for another period as the director may specify. This report shall include other relevant information as specified by rule of the director. The director shall not consent to a surrender and an order of revocation shall not be considered final until the closing audit report has been filed with the director and all concerns raised by the director therefrom have been resolved by the plan, as determined by the director. For good cause, the director may waive the requirement of a closing audit report.(c) Except as otherwise provided in this subdivision, each plan shall submit financial statements prepared as of the close of its fiscal year within 120 days after the close of the fiscal year. The financial statements referred to in this subdivision and in subdivisions (a) and (b) of this section shall be accompanied by a report, certificate, or opinion of an independent certified public accountant or independent public accountant. The audits shall be conducted in accordance with generally accepted auditing standards and the rules and regulations of the director. However, financial statements from public entities or political subdivisions of the state whose audits are conducted by a county grand jury shall be submitted within 180 days after the close of the fiscal year and need not include a report, certificate, or opinion by an independent certified public accountant or an independent public accountant, and the audit shall be conducted in accordance with governmental auditing standards.(d) (1) The financial statements required pursuant to subdivisions (a) to (c), inclusive, shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the director may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each plan in a manner prescribed by the director.(3) For the purposes of this subdivision:(A) Adjudicated means a plan or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 1367.01.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by a plan or other person subject to this chapter.(d)(e) A plan, solicitor, or solicitor firm shall make any special reports to the director as the director may from time to time require.(e)(f) For good cause and upon written request, the director may extend the time for compliance with subdivisions (a), (b), and (h) of this section. (i).(f)(g) A plan, solicitor, or solicitor firm shall, when requested by the director, for good cause, submit its unaudited financial statement, prepared in accordance with generally accepted accounting principles and consisting of at least a balance sheet and statement of income as of the date and for the period specified by the director. The director may require the submission of these reports on a monthly or other periodic basis.(g)(h) If the report, certificate, or opinion of the independent accountant referred to in subdivision (c) is in any way qualified, the director may require the plan to take any action as the director deems appropriate to permit an independent accountant to remove the qualification from the report, certificate, or opinion.(h)(i) The director may reject any financial statement, report, certificate, or opinion filed pursuant to this section by notifying the plan, solicitor, or solicitor firm required to make this filing of its rejection and the cause thereof. Within 30 days after the receipt of the notice, the person shall correct the deficiency, and the failure so to do shall be deemed a violation of this chapter. The director shall retain a copy of all filings so rejected.(i)(j) The director may make rules and regulations specifying the form and content of the reports and financial statements referred to in this section, and may require that these reports and financial statements be verified by the plan or other person subject to this chapter in a manner as the director may prescribe.
1384. (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report containing audited financial statements covering the 12-calendar months next preceding the month of receipt of the request, or another period as the director may require.
(b) On or before 105 days after the date of a notice of surrender or order of revocation, a plan shall file with the director a closing audit report containing audited financial statements. The reporting period for the closing audit report shall be the 12-month period preceding the date of the notice of surrender or order of revocation, or for another period as the director may specify. This report shall include other relevant information as specified by rule of the director. The director shall not consent to a surrender and an order of revocation shall not be considered final until the closing audit report has been filed with the director and all concerns raised by the director therefrom have been resolved by the plan, as determined by the director. For good cause, the director may waive the requirement of a closing audit report.
(c) Except as otherwise provided in this subdivision, each plan shall submit financial statements prepared as of the close of its fiscal year within 120 days after the close of the fiscal year. The financial statements referred to in this subdivision and in subdivisions (a) and (b) of this section shall be accompanied by a report, certificate, or opinion of an independent certified public accountant or independent public accountant. The audits shall be conducted in accordance with generally accepted auditing standards and the rules and regulations of the director. However, financial statements from public entities or political subdivisions of the state whose audits are conducted by a county grand jury shall be submitted within 180 days after the close of the fiscal year and need not include a report, certificate, or opinion by an independent certified public accountant or an independent public accountant, and the audit shall be conducted in accordance with governmental auditing standards.
(d) (1) The financial statements required pursuant to subdivisions (a) to (c), inclusive, shall include all of the following information for each month:
(A) The number of claims processed or adjudicated.
(B) The number of claims denied or partially denied.
(C) The total cost of claims denied or partially denied.
(D) The number of in-network claims denied or partially denied.
(E) The number of prior authorization requests denied or partially denied.
(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:
(i) Out-of-network provider.
(ii) Excluded service.
(iii) Lack of prior authorization or referral.
(iv) Medical necessity reasons.
(v) Experimental or investigational treatment.
(vi) Lack of efficacy.
(vii) Medical records not provided or insufficient information.
(viii) Patient ineligibility or coverage rule.
(ix) Lack of timely filing.
(x) Any other reason as the director may prescribe.
(G) The number of internal appeals or grievances filed or processed.
(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.
(I) The number of external appeals or grievances filed.
(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.
(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.
(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each plan in a manner prescribed by the director.
(3) For the purposes of this subdivision:
(A) Adjudicated means a plan or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.
(B) Artificial intelligence has the same meaning as in Section 1367.01.
(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by a plan or other person subject to this chapter.
(d)
(e) A plan, solicitor, or solicitor firm shall make any special reports to the director as the director may from time to time require.
(e)
(f) For good cause and upon written request, the director may extend the time for compliance with subdivisions (a), (b), and (h) of this section. (i).
(f)
(g) A plan, solicitor, or solicitor firm shall, when requested by the director, for good cause, submit its unaudited financial statement, prepared in accordance with generally accepted accounting principles and consisting of at least a balance sheet and statement of income as of the date and for the period specified by the director. The director may require the submission of these reports on a monthly or other periodic basis.
(g)
(h) If the report, certificate, or opinion of the independent accountant referred to in subdivision (c) is in any way qualified, the director may require the plan to take any action as the director deems appropriate to permit an independent accountant to remove the qualification from the report, certificate, or opinion.
(h)
(i) The director may reject any financial statement, report, certificate, or opinion filed pursuant to this section by notifying the plan, solicitor, or solicitor firm required to make this filing of its rejection and the cause thereof. Within 30 days after the receipt of the notice, the person shall correct the deficiency, and the failure so to do shall be deemed a violation of this chapter. The director shall retain a copy of all filings so rejected.
(i)
(j) The director may make rules and regulations specifying the form and content of the reports and financial statements referred to in this section, and may require that these reports and financial statements be verified by the plan or other person subject to this chapter in a manner as the director may prescribe.
SEC. 2. Section 10127.19 of the Insurance Code is amended to read:10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b).(b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows:(1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a).(2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision.(c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the departments internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year.(d) (1) The reports required pursuant to subdivisions (a) and (b) shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the department may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each insurer or MEWA in a manner prescribed by the commissioner.(3) For the purposes of this subdivision:(A) Adjudicated means an insurer, MEWA, or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 10123.135.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by an insurer, MEWA, or other person subject to this chapter.
SEC. 2. Section 10127.19 of the Insurance Code is amended to read:
### SEC. 2.
10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b).(b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows:(1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a).(2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision.(c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the departments internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year.(d) (1) The reports required pursuant to subdivisions (a) and (b) shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the department may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each insurer or MEWA in a manner prescribed by the commissioner.(3) For the purposes of this subdivision:(A) Adjudicated means an insurer, MEWA, or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 10123.135.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by an insurer, MEWA, or other person subject to this chapter.
10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b).(b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows:(1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a).(2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision.(c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the departments internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year.(d) (1) The reports required pursuant to subdivisions (a) and (b) shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the department may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each insurer or MEWA in a manner prescribed by the commissioner.(3) For the purposes of this subdivision:(A) Adjudicated means an insurer, MEWA, or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 10123.135.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by an insurer, MEWA, or other person subject to this chapter.
10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b).(b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows:(1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a).(2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision.(c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the departments internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year.(d) (1) The reports required pursuant to subdivisions (a) and (b) shall include all of the following information for each month:(A) The number of claims processed or adjudicated.(B) The number of claims denied or partially denied.(C) The total cost of claims denied or partially denied.(D) The number of in-network claims denied or partially denied.(E) The number of prior authorization requests denied or partially denied.(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:(i) Out-of-network provider.(ii) Excluded service.(iii) Lack of prior authorization or referral.(iv) Medical necessity reasons.(v) Experimental or investigational treatment.(vi) Lack of efficacy.(vii) Medical records not provided or insufficient information.(viii) Patient ineligibility or coverage rule.(ix) Lack of timely filing.(x) Any other reason as the department may prescribe.(G) The number of internal appeals or grievances filed or processed.(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.(I) The number of external appeals or grievances filed.(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each insurer or MEWA in a manner prescribed by the commissioner.(3) For the purposes of this subdivision:(A) Adjudicated means an insurer, MEWA, or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.(B) Artificial intelligence has the same meaning as in Section 10123.135.(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by an insurer, MEWA, or other person subject to this chapter.
10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b).
(b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows:
(1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a).
(2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision.
(c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the departments internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year.
(d) (1) The reports required pursuant to subdivisions (a) and (b) shall include all of the following information for each month:
(A) The number of claims processed or adjudicated.
(B) The number of claims denied or partially denied.
(C) The total cost of claims denied or partially denied.
(D) The number of in-network claims denied or partially denied.
(E) The number of prior authorization requests denied or partially denied.
(F) The number of claims denied or partially denied, disaggregated by each of the following reasons:
(i) Out-of-network provider.
(ii) Excluded service.
(iii) Lack of prior authorization or referral.
(iv) Medical necessity reasons.
(v) Experimental or investigational treatment.
(vi) Lack of efficacy.
(vii) Medical records not provided or insufficient information.
(viii) Patient ineligibility or coverage rule.
(ix) Lack of timely filing.
(x) Any other reason as the department may prescribe.
(G) The number of internal appeals or grievances filed or processed.
(H) The number of claims denied or partially denied that were overturned through internal appeals or grievances processes.
(I) The number of external appeals or grievances filed.
(J) The number of claims denied or partially denied that were overturned through external appeals or grievances processes.
(K) The number of claims denied or partially denied that at any point were processed, adjudicated, or reviewed with artificial intelligence or other predictive algorithms.
(2) The department shall publish on its internet website monthly claims denial information described in paragraph (1) for each insurer or MEWA in a manner prescribed by the commissioner.
(3) For the purposes of this subdivision:
(A) Adjudicated means an insurer, MEWA, or other person subject to this chapter has made a determination, whether full or partial, regarding claims payment or coverage.
(B) Artificial intelligence has the same meaning as in Section 10123.135.
(C) Claim means a request for payment or coverage of health care services, including prior authorization requests, submitted to or received by an insurer, MEWA, or other person subject to this chapter.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
### SEC. 3.