US Laws, Codes, Statutes & Cases

796.01.  Disability insurers and nonprofit hospital service plans
shall, upon rejecting a claim from a health care provider or a
patient, and upon their demand, disclose the specific rationale used
in determining why the claim was rejected.  Nothing in this section
is intended to expand or restrict the ability of a health care
provider or a patient from having health care coverage approved in
advance of services.



796.02.  Compensation of a person retained by a disability insurer
to review claims for health care services shall not be based on
either of the following:
   (a) A percentage of the amount by which a claim is reduced for
payment.
   (b) The number of claims or the cost of services for which the
person has denied authorization or payment.



796.03.  This article does not apply to services or benefits
provided pursuant to Medi-Cal, including services or benefits
provided under Chapters 7 (commencing with Section 14000) and 8
(commencing with Section 14200) of Part 3 of Division 9 of the
Welfare and Institutions Code.



796.04.  A disability insurer that provides coverage for hospital,
medical, or surgical expenses and a nonprofit hospital service plan
that authorizes a specific type of treatment for services covered
under a policyholder's contract or plan by a provider shall not
rescind or modify this authorization after the provider renders the
health care service in good faith and pursuant to the authorization.
This section shall not be construed to expand or alter the benefits
available or the terms and conditions of the contract as may be
agreed upon between a policyholder, certificate holder, or trust, and
the insurer.