SB 180 Summary

• Redefines "clinical peer" to require specific board certifications or doctoral degrees for reviewers of child/adolescent and adult substance use disorder and mental disorder cases, effective January 1, 2025.

• Requires health carriers to use documented clinical review criteria based on sound clinical evidence for utilization reviews, with specific criteria mandated for substance use disorders (American Society of Addiction Medicine standards) and mental health treatments (American Academy of Child and Adolescent Psychiatry or American Psychiatric Association guidelines).

• Establishes a rebuttable presumption that health care services ordered by licensed professionals are medically necessary, placing the burden on health carriers to prove medical necessity is not met.

• Allows health care professionals to request a conference with a clinical peer to challenge initial adverse determinations based on medical necessity, with the clinical peer granted authority to reverse the determination without this counting as a formal grievance.

• Ensures clinical peers reviewing adverse determinations are independent from initial reviewers and must consider all submitted patient information and documentation, with health carriers required to provide new evidence to patients before issuing decisions.