§ 22854.5
510 words·~2 min read·
/ca/government-code/22854-5A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(a)A health benefit plan or contractor, or an entity offering services relating to the administration of health benefit plans to members and annuitants, shall disclose to the board, staff, and any contractor or consultant of the system, the cost, utilization, actual claim payments, and contract allowance amounts for health care services rendered by participating hospitals to each member and annuitant.
(b)The information specified in subdivision
(a)shall be deemed confidential information and protected in accordance with the federal Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Sec. 300gg), the final regulations issued pursuant to the act by the United States Department of Health and Human Services (45 C.F.R. Parts 160 and 164), and the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code). Information provided to the board, staff, and any contractor or consultant of the system shall not include individual member or annuitant identifying information.
(c)The information specified in subdivision
(a)shall be deemed to be confidential trade secret information in accordance with subdivision
(d)of Section 3426.1 of the Civil Code and Section 1060 of the Evidence Code.
(d)The board shall not disclose the information specified in subdivision
(a)in either individual or aggregated form to any other health care service plan or insurer or any entity offering services relating to the administration of health benefit plans, and shall not make this information available to the public, including, but not limited to, any summaries, compilations, or rankings derived from this information. This information shall be used only to make decisions that materially affect the members and annuitants of the health benefits program established by the board.
(e)Any staff, contractor, or consultant to whom information is disclosed pursuant to subdivision
(a)shall be subject to all the restrictions in this section regarding the confidentiality and nondisclosure of that information.
(f)The information specified in subdivision (a), in either individual or aggregated form, shall be exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1) pursuant to Section 7927.705.
(g)Upon request from a hospital, the board shall, on an annual basis, provide the hospital a reasonable opportunity to validate the data that has been provided to the board by a health insurer, health care service plan, or entity pursuant to subdivision (a).
(h)For purposes of this section:
(1)“Actual claim payment” means the actual amount paid by the health care plan or administrator to the participating hospital for a health care service rendered to a member or annuitant, exclusive of member or annuitant cost sharing and any other payment adjustments.
(2)“Contract allowance amounts” means the negotiated rate that the participating hospital agrees to accept as payment for a health care service rendered to a member or annuitant under the provider agreement between the health plan or administrator and the participating hospital.
(3)“Cost” means the full amount billed by the participating hospital for a health care service rendered to a member or annuitant.