Relating to utilization review organizations’ use of artificial intelligence, prior authorization determinations and exemptions, and audits, and including applicability provisions

“Downgrade” is defined in the bill. A URO shall not deny or downgrade a request for authorization unless the decision is made by a qualified reviewer or clinical peer and the URO provides the health care provider (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 (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, the qualified reviewer or clinical peer shall consider the known clinical aspects of the services under review. The commissioner of insurance (commissioner) may adopt rules to administer this division of the bill. This division of the bill applies to requests for authorization made before January 1, 2027, if the request has not been finally determined on or before that date, and requests for authorization made on or after January 1, 2027. DIVISION II —— PRIOR AUTHORIZATION —— CANCER-RELATED EXEMPTIONS. A health carrier (carrier) shall not require authorization for, or impose additional utilization review requirements on, a person for a cancer-related screening (screening) if the screening is recommended by the person’s health care professional (professional) based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology. The director of health and human services shall adopt rules, and the commissioner may adopt rules, to administer this division of the bill as detailed in the bill. This division of the bill applies to health benefit plans (plans) delivered, issued for delivery, continued, or renewed on or after January 1, 2027, and requests for authorization for a screening recommended by a person’s professional if the request is made before January 1, 2027, and has not been finally determined on or before that date. The bill also applies to such requests made on or after January 1, 2027. DIVISION III —— PRIOR AUTHORIZATION —— LIFE-THREATENING HEALTH CONDITIONS. A carrier shall not require authorization for, or impose additional utilization review requirements on, a person for diagnosis and treatment of a health condition (condition) that develops or becomes evident while the person is receiving treatment at an inpatient facility and is reasonably determined by a professional to be a life-threatening condition unless the person receives immediate assessment and treatment. The commissioner may adopt rules to administer this division of the bill. This division of the bill applies to plans delivered, issued for delivery, continued, or renewed on or after January 1, 2027, and requests for authorization for diagnosis and treatment of a condition that develops or becomes evident in a person while receiving treatment at an inpatient facility if the condition is life-threatening unless the person receives immediate assessment and treatment, the request is made before January 1, 2027, and the request has not been finally determined on or before that date. DIVISION IV —— UTILIZATION REVIEW ORGANIZATIONS —— AUDITS. A carrier or URO that conducts an audit shall notify the provider that submitted the claim of the initiation of the audit no later than days after the carrier selects the claim for audit. “Audit” is defined in the bill. A carrier or URO shall complete an audit and issue a determination to the provider no later than days after the carrier or URO receives all documentation regarding the claim from the provider. A provider who submitted a claim that is the subject of an audit and who receives an adverse determination regarding the claim may appeal it no later than days after the provider receives the determination. A carrier or URO shall consider an appeal and issue a final determination no later than days after receiving notice of an appeal. If a carrier or URO violates the bill, the claim shall be automatically approved by the carrier or URO and promptly paid, including interest. The commissioner may adopt rules to administer and enforce this division of the bill. This division of the bill applies to audits initiated on or after January 1, 2027.