Relating to prior authorization and utilization review organizations

This bill relates to prior authorization and utilization review organizations. The bill requires a utilization review organization (organization) to provide a determination to a request for prior authorization (authorization) from a health care provider (provider) within 48 hours after receipt for urgent requests or within 10 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 15 calendar days. Within 24 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 conduct an annual review and submit the findings in a report to the commissioner of insurance (commissioner). The requirements for the report are detailed in the bill. The bill also requires an organization to annually review all health care services for which a health benefit plan (plan) requires an authorization, 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. An organization shall submit an annual report containing the findings of both reviews to the commissioner, and shall include all of the information detailed in the bill. The commissioner shall submit an annual report to the general assembly containing a summary and analysis of the information in the reports. 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 received regarding the organization. Complaints received under the bill shall not be considered public records.