Health care coverage: utilization review: peer-to-peer review.

2025-2026 Regular Session Introduced by Dawn Addis

Requires rapid peer-to-peer reviews for disputed medical-necessity decisions to speed reconsideration and deem approval if the plan misses timelines.

In committee: Held under submission.

#healthcarecoverage #peer-to-peerreview #utilizationreview

Purpose / Intent

AB 510 requires health care service plans to provide a rapid “peer-to-peer” review option when a provider, enrollee, or insured appeals or grieves a decision that delays, denies, or modifies care on the basis of medical necessity. The bill is intended to speed clinical reconsideration by a qualified clinician and to reduce delays in access to medically necessary care.

Key provisions

Adds Section 1367.017 to the Health and Safety Code establishing a statutory right to request a peer-to-peer review after a utilization review decision that delays, denies, or modifies care for medical necessity reasons.

Reviewer qualifications:

Primary reviewer: a “peer physician” — a licensed physician competent to evaluate the clinical issues and of the same or similar specialty as the requesting provider.
If the requesting provider is not a physician, the review may be conducted by a “peer health care professional” — a licensed health care professional with comparable competency and specialty.
Peer-to-peer reviews may be performed by a plan’s contracted specialist reviewer if that reviewer meets the peer criteria.

Process requirements:

Upon request, the plan must directly and expeditiously connect the requesting provider with the peer reviewer without requiring intermediate contacts with other plan staff.
Timeline: peer-to-peer review must occur within two business days of the request.
For cases involving an imminent and serious threat to health (e.g., severe pain, risk of loss of life/limb/major function), review must occur in a timely fashion appropriate to the condition and not exceed 24 hours.

Consequence for missed timelines: if the plan fails to meet the required timeline, the request for the health care service is deemed approved and supersedes any prior delay, denial, or modification.

Conforming amendment to Section 1368.01 (grievance system) to incorporate the new peer-to-peer requirement alongside existing grievance timelines and expedited review provisions.

Who is affected

Health care service plans subject to the Knox‑Keene Act (Department of Managed Health Care oversight).

Providers (physicians and other licensed health care professionals) who request peer-to-peer reviews.

Enrollees and insureds whose care was delayed, denied, or modified on medical necessity grounds.

Plans may face operational impacts to ensure timely direct connection to qualified peer reviewers.

Procedural / fiscal notes

Introduced 02/10/2025; amended in committee (April 2025); referred to Assembly Appropriations; held under submission 05/23/2025.

Legislative counsel’s digest notes that willful violations of Knox‑Keene are criminal and that the bill imposes a state‑mandated local program; the bill states no state reimbursement is required for the mandate (per cited reason in digest).

Potential impacts (summary)

Likely to accelerate clinical reconsideration and reduce denials/delays when plans miss tight review windows.

Imposes operational requirements on plans to staff or contract with qualified peer reviewers and maintain rapid direct-connection processes.

May increase approvals by operation of the “deemed approved” provision if plans fail to meet timelines.

Bill