Relating to prior authorization exemptions for certain health care providers for specific health care services

This bill relates to prior authorization exemptions for certain health care providers for certain health care services. The bill requires health carriers (carrier) that require prior authorization for certain health care services (services) to grant a health care provider (provider) an exemption, if, in the most recent evaluation period (period), the carrier has approved not less than percent of the prior authorization requests submitted by that provider for the specific service. “Exemption” is defined in the bill as an exception to a carrier’s requirement that a provider obtain prior authorization for a specific service. “Evaluation period” is defined in the bill. A carrier shall conduct an evaluation of each provider that is contracted with the carrier to provide services to the carrier’s covered persons a minimum of once every three months to determine if the provider qualifies for an exemption. “Evaluation” is defined in the bill. A carrier may continue an exemption without conducting an evaluation for a specific evaluation period. A provider is not required to request a provider’s exemption from a carrier to qualify for an exemption. No later than five calendar days after a provider qualifies for an exemption, the carrier shall provide a notice to the provider that includes a statement that the provider qualifies for an exemption, a complete list of all health benefit plans and services to which the exemption applies, and the duration of the exemption. If a provider submits a prior authorization request for a service for which the provider qualifies for an exemption, the carrier shall promptly provide the provider with the same notice. If a carrier notifies a provider of the carrier’s decision to rescind the provider’s exemption and the provider fails to appeal the decision within calendar days, the provider’s exemption is rescinded effective calendar days after the date of the carrier’s notice. If the provider appeals the carrier’s decision within the 30-day appeal period and the decision is upheld on appeal, the provider’s exemption shall be rescinded five calendar days after the date the decision is upheld. A carrier may deny an exemption for a provider for a specific service if the carrier provides the provider with sufficient statistics and documentation for the relevant period to demonstrate that the provider does not meet the carrier’s criteria for exemption. The carrier must satisfy the notification requirements detailed in the bill. A carrier may rescind a provider’s exemption if a retrospective review of a random sample of the provider’s claims show that less than percent of the claims for the specific service met the medical necessity and appropriateness criteria used by the carrier for conducting a prior authorization review for the specific service during the relevant period. “Random sample” is defined in the bill. The determination must be made by a health care professional licensed to practice medicine in this state, and if the determination is made with respect to a health care professional who is a physician, the determination must be made by a physician licensed in this state who has either the same or a similar medical specialty as the health care professional. The carrier must notify the provider not less than days before the date the rescission is effective. The carrier must provide the provider with documentation, as detailed in the bill, with the notice. A provider shall have the right to appeal an adverse exemption determination as detailed in the bill, and the carrier and provider are bound by the appeal decision or the independent review organization’s (organization) determination. If a carrier’s adverse exemption determination is overturned by an organization, the carrier shall not attempt to rescind the provider’s exemption prior to the end of the next occurring period. A carrier shall not retroactively deny a service on the basis of the carrier’s rescission of the provider’s exemption, even if the carrier’s decision is affirmed on appeal or by an organization’s determination. If an appeal or an organization’s determination affirms the rescission or denial of a provider’s exemption for a specific service, the provider shall be eligible for an exemption for the same service after the last day of the three-month period immediately following the period that was the basis for the denial or rescission. A carrier shall not deny or reduce payment on a provider’s claim based on the medical necessity or appropriateness of care for a service for which the provider qualified for an exemption, unless the provider knowingly and materially misrepresented the service in the claim with the specific intent to deceive the carrier and to obtain an unlawful claim payment on the claim. A carrier shall not conduct a retrospective review of a service provided by a provider who has been granted an exemption for the service except in the circumstances detailed in the bill. The bill shall not be construed to permit a provider to provide a service outside the scope of the provider’s license, or to require a carrier to pay a claim submitted by a provider for a service outside the scope of the provider’s license. The bill applies to all health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027.