Relating to health carriers standards of conduct; utilization review organizations, artificial intelligence, audits, and prior authorizations; certificate of need processes; and including applicability provisions

If a health carrier (carrier) conducts an audit of a clean claim, the carrier shall reimburse the provider for the reasonable administrative costs incurred by the provider to respond to the audit. “Audit” and “clean claim” are defined in the bill. A carrier that conducts an audit shall notify the provider of the initiation of the audit no later than days after selecting the clean claim for audit. A carrier shall complete an audit and issue a determination on the clean claim within days of receiving all requested documentation from the provider. A provider that submitted a clean claim subject to an audit, and that receives an adverse determination, may appeal the determination within days. A carrier shall consider an appeal and issue a final determination on the clean claim no later than days after receiving notice of the appeal. If a carrier violates the audit timeline requirements, the clean claim shall be automatically approved and promptly paid, including interest at the rate of percent per annum. The audit requirements shall not apply to a claim that is under active fraud investigation by a state or federal authority, or to a federal program where audits are mandated by federal law. Under the bill, a carrier shall not: (1) impose on a provider any financial penalty, reimbursement reduction, or administrative fee, or terminate a provider’s participation in the carrier’s network, based on the provider’s referral to or affiliation with an out-of-network provider; (2) interfere with, or participate in any capacity in, a provider’s decisions regarding staffing and referral, except as otherwise provided by law; and (3) offer, attempt to enforce, or enforce an agreement or amendment to an agreement with a provider without providing an opportunity for negotiation, and a contract term that violates the bill shall be void and unenforceable. A violation of this division of the bill by a carrier shall constitute an unfair method of competition or unfair or deceptive act or practice. The carrier shall be subject to civil penalties. In any action brought by a provider against a carrier, the provider shall be entitled to recover costs of litigation, including reasonable attorney fees and other expenses, regardless of whether the provider prevails in such action. The commissioner shall adopt rules to administer and enforce this division.4(3). DIVISION II —— PRIOR AUTHORIZATIONS. A utilization review organization (URO) shall not deny or downgrade a request for authorization unless: (1) the decision is made by a qualified reviewer or clinical peer; and (2) the URO provides the provider requesting authorization a written statement citing the reasons for the decision, explaining the appeals process, and a written attestation as described by the bill. If a request for authorization is denied, the URO shall notify the provider within seven days and conduct a consultation as described by the bill. “Clinical peer” and “qualified reviewer” are defined in the bill. If a URO’s decision to deny or downgrade a request for authorization is appealed by the requesting provider or covered person, the appeal shall be conducted by a qualified reviewer or clinical peer who was not involved in the initial denial or downgrade. When conducting an appeal of a request for authorization, the qualified reviewer or clinical peer shall consider the known clinical aspects of the health care services (services) under review, including but not limited to medical records relevant to the medical condition and any relevant medical literature submitted by the provider. A violation of the bill’s requirements for denial or downgrade of an authorization by a URO or a carrier shall constitute an unfair method of competition or unfair or deceptive act or practice. The carrier shall be subject to civil penalties. In any action brought by a provider against a carrier, the provider shall be entitled to recover costs of litigation, including reasonable attorney fees and other expenses, regardless of whether the provider prevails in such action. The commissioner may adopt rules to administer this division of the bill. A carrier shall not require authorization for, or impose additional utilization review requirements on, a covered person for: (1) a cancer-related screening or cancer-related preventative service recommended by the covered person’s professional based on the national comprehensive cancer network clinical practice guidelines in oncology; or (2) the diagnosis and treatment of a health condition that develops or becomes evident in a covered person while receiving treatment at an inpatient facility, and the health condition is reasonably determined by a professional to be a life threatening condition unless the covered person receives immediate assessment and treatment. This division of the bill applies to health benefit plans delivered, issued for delivery, continued, or renewed on or after January 1, 2027, and requests for prior authorization for a cancer-related screening or cancer-related preventative health care service if the screening or service is recommended by the covered person’s professional, the request is made before January 1, 2027, and the request has not been finally determined on or before that date.