Code Section Group

Health and Safety Code - HSC


  ( Division 2 enacted by Stats. 1939, Ch. 60. )

CHAPTER 2.2. Health Care Service Plans [1340 - 1399.874]

  ( Chapter 2.2 added by Stats. 1975, Ch. 941. )

ARTICLE 9.5. Claims Reviewers [1399.55 - 1399.57]
  ( Article 9.5 added by Stats. 1992, Ch. 544, Sec. 1. )


Health care 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.

(Added by Stats. 1992, Ch. 544, Sec. 1. Effective January 1, 1993.)


Compensation of a person retained by a health care service plan 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.

(Amended by Stats. 1995, Ch. 787, Sec. 2. Effective January 1, 1996.)


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.

(Added by Stats. 1992, Ch. 544, Sec. 1. Effective January 1, 1993.)

HSCHealth and Safety Code - HSC9.5.