PacifiCare to Offer Members Outside Reviews

PacifiCare Health Systems Inc., one of two Southern California managed health-care plans 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 next 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.

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. in Southern California.

The lawsuits, which also name Cigna Healthcare, Prudential Health Care and Humana Inc., allege that the plans “misrepresent that coverage and treatment decisions are made on the basis of ‘medical necessity,’ ” interfering with doctors’ medical judgments.

PacifiCare spokeswoman Lisa Boyette said the new review system did not stem from the suit.