A Study of Coverage Decision-Making by Managed Care Organizations

This document is about a study that aims to describe the processes of coverage decision-making within managed care organizations, determine how patient and service characteristics affect the use and outcomes of appeals procedures, investigate how procedural features relate to appeal behaviors and outcomes, and explore the role of clinical factors in the use and outcomes of coverage decision-making processes. The study focuses on three large managed care plans in California and utilizes administrative data as well as interviews with plan officials to gather information.