Relating to prior authorization and utilization review organizations

This bill relates to prior authorizations and exemptions by health benefit plans and utilization review organizations. The bill requires a utilization review organization (organization) to respond to a request for prior authorization (authorization) from a health care provider (provider) within hours after receipt for urgent requests or within calendar days for nonurgent requests, unless there are complex or unique circumstances, or the organization is experiencing an unusually high volume of authorization requests, then an organization must respond within calendar days. Within hours after receipt of an authorization request, the organization shall notify a provider of, or make available, a receipt for the authorization request. The bill requires an organization to annually review all health care services for which authorization is required and to eliminate authorization requirements for health care services for which authorization requests are so routinely approved that the authorization requirement is not justified as it does not promote health care quality or reduce health care spending. Complaints regarding an organization’s compliance with the bill may be directed to the insurance division, and the insurance division shall notify an organization of all complaints. Complaints received under the bill shall not be considered public records. The bill requires, on or before January 15, 2026, all health carriers (carriers) that deliver, issue for delivery, continue, or renew a health benefit plan (plan) in this state on or after January 1, 2026, and that require prior authorizations, to implement a pilot program that exempts a subset of participating providers, including primary health care providers, from certain authorization requirements. Each carrier shall make available for each plan details about the plan’s authorization exemption requirements on the carrier’s internet site, including the carrier’s criteria for a provider to qualify for the exemption program, the health care services that are exempt from authorization requirements, the estimated number of providers who are eligible for the program, including the providers’ specialties and the percentage of the providers that are primary care providers, and contact information for consumers and providers to contact the plan about the exemption program or a provider’s eligibility for the exemption program. On or before January 15, 2027, each carrier required to implement an authorization exemption program (program) under the bill shall submit to the commissioner of insurance a report containing the results of the program, including an analysis of the costs and savings of the program, the plan’s recommendations for continuing or expanding the program, feedback received by each plan, and an assessment of the administrative costs incurred by each of the carrier’s plans to administer and implement authorization requirements under the program.