Prior Authorization Requirements Health Care Service

Health care coverage - prior authorization for health care services - publication of requirements and restrictions - deadline for making determination - required criteria - exceptions for compliant providers - duration of prior authorization - rules. With regard to the prior authorization process used by carriers or private utilization review organizations (organizations) acting on behalf of carriers to review and determine whether a particular health care service prescribed by a health care provider is approved as a covered benefit under the patient's health benefit plan, the act requires carriers and organizations to:

• Publish and update their prior authorization requirements and restrictions;
• Comply with specified deadlines for making a determination on a prior authorization request;
• Use current, clinically based prior authorization criteria that are aligned with other quality initiatives of the carrier or organization and with other carriers' and organizations' prior authorization criteria for the same health care service; and
• Consider limiting the use of prior authorization to providers whose prescribing or ordering patterns differ significantly from the patterns of their peers after adjusting for patient mix and other relevant factors.

The act authorizes a carrier or organization to offer providers with a history of adherence to the carrier's or organization's prior authorization requirements an alternative to prior authorization, including an exemption from prior authorization for providers with an 80% approval rate of prior authorization requests over the previous 12 months. Carriers and organizations are to annually reevaluate a provider's eligibility for exemption from or other alternative to prior authorization requirements.

If a carrier or organization fails to make a determination within the time required, the request is deemed approved.

An approved prior authorization request is valid for at least 180 days, with some exceptions, and continues for the duration of the authorized course of treatment.

The commissioner of insurance is authorized to adopt rules as necessary to implement the act.

(Note: This summary applies to this bill as enacted.)