- Base coverage authorization and medical necessity determinations on generally accepted and evidence-based criteria and disclose the criteria to health care providers and policyholders;
- Disclose the process that must be followed to obtain coverage authorizations and medical necessity determinations to providers and policyholders;
- Ensure that the authorizations and determinations are made by a licensed provider in good standing in the same field or specialty as the requesting provider; and
- Categorize care for a recurring condition as a new episode if the same provider has not treated the policyholder within the last 30 days.
The contract between the health care provider and intermediary must not:
- Allow for utilization management or utilization review as direct medical care or quality improvement;
- Impose different or tiered authorization standards and criteria for participating providers of the same licensed profession in the same network;
- Require prior authorization for coverage for the evaluation and management in the initial visit; or
- Require a provider to discount billed charges for physical rehabilitation services or products not covered under a health coverage plan unless the carrier or intermediary has disclosed to the provider and the carrier's policyholders in writing that providers are required to give the discount.
The bill prohibits a carrier from providing incentives to an intermediary who has a contract for its coverage authorizations and medical necessity determinations for services provided to a policyholder.
The bill makes a violation of these terms an unfair or deceptive trade practice in the business of insurance.
(Note: This summary applies to this bill as introduced and does not reflect any amendments that were subsequently adopted.)