PacifiCare to Offer Access to Appeals

PacifiCare Health Systems Inc., one of two Southern California managed health care plans being sued over benefit coverage, said Tuesday that it will provide its 2.7 million commercial members in nine states access to an independent review of medical coverage decisions by May.

The Santa Ana company said the appeals process, called Independent External Review, generally takes 10 to 30 days to complete. The appeals process will be offered to consumers in its health maintenance organization, preferred-provider organization and point-of-service health plans.

PacifiCare said it will contract with several independent review organizations in each state to oversee the program. The health plan will be bound to any decision reached and accountable for the cost of the review.

The 1 million members in its Secure Horizons Medicare HMO already have access to the external review process as required by its participation in the Medicare program.

PacifiCare was sued last week in one of a series of actions filed in federal court in Hattiesburg, Miss., that target five organizations around the nation, including Foundation Health Systems Inc. The lawsuits allege that the plans “misrepresent that coverage and treatment decisions are made on the basis of ‘medical necessity,’ ” interfering with doctors’ medical judgments.

The company would not comment on the lawsuits, but spokeswoman Lisa Boyette said the new review system did not stem from the lawsuit.

“This is something we’ve been working on for quite some time,” she said. “It’s a way to make the plan more user-friendly.”