Alabama 2025 Regular Session

Alabama House Bill HB557 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	HB557INTRODUCED
2	2	Page 0
3	3	HB557
4	4	5VL5133-1
5	5	By Representative Datcher
6	6	RFD: Insurance
7	7	First Read: 09-Apr-25
8	8	1
9	9	2
10	10	3
11	11	4
12	12	5 5VL5133-1 04/01/2025 JC (L)lg 2025-835
13	13	Page 1
14	14	First Read: 09-Apr-25
15	15	SYNOPSIS:
16	16	Under existing law, "utilization review," the
17	17	process by which health insurers determine whether or
18	18	not to pay or reimburse for health care services, is
19	19	regulated under the Alabama Department of Public
20	20	Health.
21	21	This bill would place regulation of utilization
22	22	review functions under the Department of Insurance.
23	23	This bill would require health insurers to
24	24	annually report the number of coverage requests denied
25	25	to the Department of Insurance and make their coverage
26	26	criteria accessible to enrollees and health care
27	27	providers.
28	28	This bill would require coverage determinations
29	29	to be made and communicated to a health care provider
30	30	within 72 hours for nonurgent care requests and 24
31	31	hours for urgent care requests.
32	32	This bill would require that coverage
33	33	determinations be reviewed by a licensed health care
34	34	professional.
35	35	This bill would also require the Department of
36	36	Insurance to establish an ombudsman to receive and
37	37	investigate complaints from enrollees and health care
38	38	providers concerning coverage decisions.
39	39	This bill would further provide enforcement
40	40	1
41	41	2
42	42	3
43	43	4
44	44	5
45	45	6
46	46	7
47	47	8
48	48	9
49	49	10
50	50	11
51	51	12
52	52	13
53	53	14
54	54	15
55	55	16
56	56	17
57	57	18
58	58	19
59	59	20
60	60	21
61	61	22
62	62	23
63	63	24
64	64	25
65	65	26
66	66	27
67	67	28 HB557 INTRODUCED
68	68	Page 2
69	69	This bill would further provide enforcement
70	70	powers to the Department of Insurance, including the
71	71	authority to impose civil fines on an insurer who
72	72	violates this act, and would recognize that an enrollee
73	73	aggrieved by a utilization review determination may
74	74	pursue civil damages.
75	75	A BILL
76	76	TO BE ENTITLED
77	77	AN ACT
78	78	Relating to health insurance; to amend Sections
79	79	27-3A-1, 27-3A-2, 27-3A-3, 27-3A-4, 27-3A-5, and 27-3A-6, Code
80	80	of Alabama 1975, to further regulate utilization review by
81	81	health insurers; to place enforcement of utilization review
82	82	requirements under the Department of Insurance; to provide
83	83	time limits for determinations of coverage and the resolution
84	84	of appeals of coverage denials; to require that determinations
85	85	of coverage be reviewed by a licensed health care
86	86	professional; to require the the Department of Insurance to
87	87	establish an ombudsman program to receive complaints from
88	88	enrollees and health care providers; to provide civil
89	89	penalties for violations of this act; and to add Section
90	90	27-3A-7 to the Code of Alabama 1975, to recognize that an
91	91	enrollee may have a civil action for damages.
92	92	BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:
93	93	Section 1. Sections 27-3A-1, 27-3A-2, 27-3A-3, 27-3A-4,
94	94	29
95	95	30
96	96	31
97	97	32
98	98	33
99	99	34
100	100	35
101	101	36
102	102	37
103	103	38
104	104	39
105	105	40
106	106	41
107	107	42
108	108	43
109	109	44
110	110	45
111	111	46
112	112	47
113	113	48
114	114	49
115	115	50
116	116	51
117	117	52
118	118	53
119	119	54
120	120	55
121	121	56 HB557 INTRODUCED
122	122	Page 3
123	123	Section 1. Sections 27-3A-1, 27-3A-2, 27-3A-3, 27-3A-4,
124	124	27-3A-5, and 27-3A-6, Code of Alabama 1975, are amended to
125	125	read as follows:
126	126	"§27-3A-1
127	127	This chapter may be cited as the "Health Care Service
128	128	Utilization Review , Accountability, and Transparency Act.""
129	129	"§27-3A-2
130	130	The purposes of this chapter are to:
131	131	(1) Promote the delivery of quality health care in a
132	132	cost-effective manner in the recognition that Alabamians have
133	133	a right to timely and equitable access to medically necessary
134	134	care.;
135	135	(2) Assure that utilization review agents adhere to
136	136	reasonable standards for conducting utilization review .;
137	137	(3) Foster greater coordination and cooperation between
138	138	health care providers and utilization review agents .;
139	139	(4) Improve communications and knowledge of benefit
140	140	plan requirements among all parties concerned before expenses
141	141	are incurred, and to require transparency and oversight of
142	142	insurance operations in order to ensure fair treatment of
143	143	Alabama consumers .;
144	144	(5) Ensure that utilization review agents maintain the
145	145	confidentiality of medical records in accordance with
146	146	applicable laws; and
147	147	(6) Hold health insurers accountable for industry
148	148	practices that deny or delay medically necessary care that
149	149	results in harm to consumers ."
150	150	"§27-3A-3
151	151	As used in this chapter, the following words and
152	152	57
153	153	58
154	154	59
155	155	60
156	156	61
157	157	62
158	158	63
159	159	64
160	160	65
161	161	66
162	162	67
163	163	68
164	164	69
165	165	70
166	166	71
167	167	72
168	168	73
169	169	74
170	170	75
171	171	76
172	172	77
173	173	78
174	174	79
175	175	80
176	176	81
177	177	82
178	178	83
179	179	84 HB557 INTRODUCED
180	180	Page 4
181	181	As used in this chapter, the following words and
182	182	phrases shall have the following meanings:
183	183	(1) ARTIFICIAL INTELLIGENCE. A machine-based system
184	184	that may include software or physical hardware that performs
185	185	tasks, based upon data set inputs, which require human-like
186	186	perception, cognition, planning, learning, communication, or
187	187	physical action and which is capable of improving performance
188	188	based upon learned experience without significant human
189	189	oversight toward influencing real or virtual environments.
190	190	(2) COMMISSIONER. The Commissioner of the Alabama
191	191	Department of Insurance.
192	192	(3) COVERAGE DENIAL. A coverage determination by a
193	193	utilization review agent to deny or refuse to certify a
194	194	payment or reimbursement for a health care treatment,
195	195	admission, service, procedure, or medication.
196	196	(4) COVERAGE DETERMINATION. A written or oral
197	197	determination made by a utilization review agent that a
198	198	treatment, admission, service, procedure, or medication, under
199	199	the enrollee's clinical circumstances is or is not: (i) a
200	200	benefit covered under the applicable health benefit plan; (ii)
201	201	medically necessary; or (iii) in compliance with another
202	202	requirement in the policies or guidelines imposed by the
203	203	utilization review agent, and thus satisfies the requirements
204	204	for payment or reimbursement.
205	205	(1)(5) DEPARTMENT. The Alabama Department of Insurance
206	206	Public Health.
207	207	(2)(6) ENROLLEE. An individual who has contracted for
208	208	or who participates in coverage under an insurance policy, a
209	209	health maintenance organization contract, a health service
210	210	85
211	211	86
212	212	87
213	213	88
214	214	89
215	215	90
216	216	91
217	217	92
218	218	93
219	219	94
220	220	95
221	221	96
222	222	97
223	223	98
224	224	99
225	225	100
226	226	101
227	227	102
228	228	103
229	229	104
230	230	105
231	231	106
232	232	107
233	233	108
234	234	109
235	235	110
236	236	111
237	237	112 HB557 INTRODUCED
238	238	Page 5
239	239	health maintenance organization contract, a health service
240	240	corporation contract, a health benefit plan an employee welfare
241	241	benefit plan, a hospital or medical services plan, or any
242	242	other benefit program providing payment, reimbursement, or
243	243	indemnification for health care costs for the individual or
244	244	the eligible dependents of the individual .
245	245	(7) HEALTH BENEFIT PLAN. a. Any plan, policy, or
246	246	contract issued, delivered, or renewed in this state by an
247	247	insurer that provides health coverage that includes payment
248	248	for hospitalization, physician care, treatment, surgery,
249	249	therapy, drugs, equipment, and any other medical expense,
250	250	regardless of whether the plan is for a group or an
251	251	individual.
252	252	b. The term does not include accident-only, specified
253	253	disease, individual hospital indemnity, credit, dental-only,
254	254	Medicare supplement, long-term care, disability income, or
255	255	other limited benefit health insurance policies, or coverage
256	256	issued as supplemental to liability insurance, workers'
257	257	compensation, or automobile medical payment insurance.
258	258	(8) INSURER. Any entity that issues, delivers, or
259	259	renews a health benefit plan, including a person as defined in
260	260	Section 27-1-2, a health maintenance organization established
261	261	under Chapter 21A, or a nonprofit health care services plan
262	262	established under Article 6, Chapter 20, Title 10A.
263	263	(9) POLICIES AND GUIDELINES. Written standards
264	264	developed or adopted by a utilization review agent, which
265	265	include parameters and considerations for prior authorization
266	266	or coverage of treatments, services, procedures, medications,
267	267	diagnostic services, therapies, final medical policies, and
268	268	113
269	269	114
270	270	115
271	271	116
272	272	117
273	273	118
274	274	119
275	275	120
276	276	121
277	277	122
278	278	123
279	279	124
280	280	125
281	281	126
282	282	127
283	283	128
284	284	129
285	285	130
286	286	131
287	287	132
288	288	133
289	289	134
290	290	135
291	291	136
292	292	137
293	293	138
294	294	139
295	295	140 HB557 INTRODUCED
296	296	Page 6
297	297	diagnostic services, therapies, final medical policies, and
298	298	medical policies in draft form.
299	299	(3)(10) PROVIDER. A health care provider duly licensed
300	300	or certified by the State of Alabama.
301	301	(11) URGENT CARE REQUEST. A request for a coverage
302	302	determination for treatments, services, procedures,
303	303	medications, diagnostic services, or therapies for which the
304	304	time period for making a nonurgent determination of prior
305	305	authorization could result in at least one of the following
306	306	outcomes for the enrollee:
307	307	a. Death.
308	308	b. Permanent impairment of health.
309	309	c. Inability to regain maximum bodily function.
310	310	d. Severe pain that cannot be adequately managed.
311	311	(4)(12) UTILIZATION REVIEW. A system for prospective
312	312	and concurrent review of the medical necessity and
313	313	appropriateness in the allocation of health care resources and
314	314	services given or proposed to be given to an individual within
315	315	this state, including a coverage determination on a request
316	316	for prior authorization or otherwise . The term does not
317	317	include elective requests for clarification of coverage.
318	318	(5)(13) UTILIZATION REVIEW AGENT. Any person or entity,
319	319	including the State of Alabama, performing a utilization
320	320	reviewthat makes coverage determinations and performs other
321	321	utilization review functions for an insurer in the
322	322	administration of a health benefit plan , except the following:
323	323	a. An agency of the federal government.
324	324	b. An agent acting on behalf of the federal government,
325	325	but only to the extent that the agent is providing services to
326	326	141
327	327	142
328	328	143
329	329	144
330	330	145
331	331	146
332	332	147
333	333	148
334	334	149
335	335	150
336	336	151
337	337	152
338	338	153
339	339	154
340	340	155
341	341	156
342	342	157
343	343	158
344	344	159
345	345	160
346	346	161
347	347	162
348	348	163
349	349	164
350	350	165
351	351	166
352	352	167
353	353	168 HB557 INTRODUCED
354	354	Page 7
355	355	but only to the extent that the agent is providing services to
356	356	the federal government.
357	357	c. The internal quality assurance program of a
358	358	hospital.
359	359	d. An employee of a utilization review agent.
360	360	e. Health maintenance organizations licensed and
361	361	regulated by the state, but only to the extent of providing a
362	362	utilization review to their own members.
363	363	f. Any entity that has a current accreditation from the
364	364	Utilization Review Accreditation Commission (URAC). However,
365	365	entities with current URAC accreditation shall file a URAC
366	366	certification with the department annually.
367	367	g.e. An entity performing utilization reviews or bill
368	368	audits, or both, exclusively for workers' compensation claims
369	369	pursuant to Section 25-5-312. If an entity also performs
370	370	services for claims other than workers' compensation, it shall
371	371	be considered a private review agent subject to this chapter
372	372	for those claims.
373	373	h.f. An entity performing utilization reviews or bill
374	374	audits, or both, exclusively for the Medicaid Agency.
375	375	i.g. A person performing utilization reviews or bill
376	376	audits, or both, exclusively for their company's health plan,
377	377	independent of a utilization review companyagent.
378	378	j.h. An insurance company licensed by the State of
379	379	Alabama performing utilization reviews or bill audits, or
380	380	both, exclusively for their company's health plan, independent
381	381	of a utilization review companyagent.
382	382	k.i. The Peer Review Committee of the Alabama State
383	383	Chiropractic Association."
384	384	169
385	385	170
386	386	171
387	387	172
388	388	173
389	389	174
390	390	175
391	391	176
392	392	177
393	393	178
394	394	179
395	395	180
396	396	181
397	397	182
398	398	183
399	399	184
400	400	185
401	401	186
402	402	187
403	403	188
404	404	189
405	405	190
406	406	191
407	407	192
408	408	193
409	409	194
410	410	195
411	411	196 HB557 INTRODUCED
412	412	Page 8
413	413	Chiropractic Association."
414	414	"§27-3A-4
415	415	(a) Utilization review agents shall adhere to the
416	416	minimum standards set forth in Section 27-3A-5.
417	417	(b) On or after July 1, 1994, a A utilization review
418	418	agent shall not conduct a utilization review in this state
419	419	unless the agent has certified to the department in writing
420	420	that the agent is in compliance with Section 27-3A-5.
421	421	Certification shall be made annually on or before July 1 of
422	422	each calendar year. In addition, a utilization review agent
423	423	shall file the following information:
424	424	(1) The name, address, telephone number, and normal
425	425	business hours of the utilization review agent.
426	426	(2) The name and telephone number of a personan
427	427	individual for the department to contact.
428	428	(3) A description of the appeal procedures for
429	429	utilization review determinations.
430	430	(c) Any material changes in the information filed in
431	431	accordance with this sectionsubsection (b) shall be filed with
432	432	the State Health Officer commissioner within 30 days of the
433	433	change.
434	434	(d) Unless exempted pursuant to paragraph f. of
435	435	subdivision (5) of Section 27-3A-3, each Each utilization
436	436	review agent, upon filing the certification under subsection
437	437	(b), shall pay an annual fee in the amount of one thousand
438	438	dollars ($1,000) to the department. All fees paid pursuant to
439	439	this subdivision shall be held by the department as expendable
440	440	receipts for the purpose of administering this chapter.
441	441	(e) No later than March 31 of each year, a utilization
442	442	197
443	443	198
444	444	199
445	445	200
446	446	201
447	447	202
448	448	203
449	449	204
450	450	205
451	451	206
452	452	207
453	453	208
454	454	209
455	455	210
456	456	211
457	457	212
458	458	213
459	459	214
460	460	215
461	461	216
462	462	217
463	463	218
464	464	219
465	465	220
466	466	221
467	467	222
468	468	223
469	469	224 HB557 INTRODUCED
470	470	Page 9
471	471	(e) No later than March 31 of each year, a utilization
472	472	review agent shall file a report with the commissioner which
473	473	shall include all of the following information for the
474	474	previous calendar year:
475	475	(1) The total number of coverage determinations.
476	476	(2) The number of coverage denials, arranged by
477	477	category of treatment, admission, service, procedure, or
478	478	medication.
479	479	(3) Within each category of coverage denial as required
480	480	under subdivision (2), the principal reason for the denial,
481	481	ranked in order according to numerical frequency.
482	482	(f) The commissioner shall make available to the public
483	483	the information filed by the insurer pursuant to subsection
484	484	(c) by posting the information in an accessible format on the
485	485	website of the department.
486	486	(e)(g) The department may adopt rules pursuant to the
487	487	Administrative Procedure Act necessary to implement this
488	488	chapter."
489	489	"§27-3A-5
490	490	(a) Except as provided in subsection (b), all All
491	491	utilization review agents shall meet the following minimum
492	492	standards:
493	493	(1) Notification of a coverage determination by the
494	494	utilization review agent shall be electronically mailed or
495	495	otherwise communicated to the provider of record or the
496	496	enrollee or other appropriate individual within two business
497	497	days72 hours of the receipt of thea request for coverage
498	498	determination and the receipt of all information necessary to
499	499	complete the review.
500	500	225
501	501	226
502	502	227
503	503	228
504	504	229
505	505	230
506	506	231
507	507	232
508	508	233
509	509	234
510	510	235
511	511	236
512	512	237
513	513	238
514	514	239
515	515	240
516	516	241
517	517	242
518	518	243
519	519	244
520	520	245
521	521	246
522	522	247
523	523	248
524	524	249
525	525	250
526	526	251
527	527	252 HB557 INTRODUCED
528	528	Page 10
529	529	complete the review.
530	530	(2) Notification of a coverage determination by the
531	531	utilization review agent shall be electronically mailed to the
532	532	provider of record or the enrollee or other appropriate
533	533	individual within 24 hours of the receipt of a request for
534	534	coverage determination for urgent care and the receipt of all
535	535	information necessary to complete the review.
536	536	(3) A request for coverage determination is deemed
537	537	granted when all information necessary to complete the review
538	538	is received by the utilization review agent and notification
539	539	is not provided to the provider of record or the enrollee or
540	540	other appropriate individual within the applicable time period
541	541	required for a nonurgent care request under subdivision (1) or
542	542	a request for urgent care under subdivision (2).
543	543	(2)(4) Any coverage determination by a utilization
544	544	review agent as to the necessity or appropriateness of ana
545	545	treatment, admission, service, or procedure, or medication
546	546	shall be reviewed by a physician or other provider or
547	547	determined in accordance with standards or for compliance with
548	548	policies and guidelines approved by a physician .
549	549	(3)(5) Any notification of coverage determination not
550	550	to certify ana treatment, admission, service, or procedure, or
551	551	medication shall include the principal reason for the
552	552	determination and the procedures to initiate an appeal of the
553	553	determination.
554	554	(4)(6) Utilization review agents shall maintain and
555	555	make available a written description of the appeal procedure
556	556	by which the enrollee or the provider of record may seek
557	557	review of a coverage determination by the utilization review
558	558	253
559	559	254
560	560	255
561	561	256
562	562	257
563	563	258
564	564	259
565	565	260
566	566	261
567	567	262
568	568	263
569	569	264
570	570	265
571	571	266
572	572	267
573	573	268
574	574	269
575	575	270
576	576	271
577	577	272
578	578	273
579	579	274
580	580	275
581	581	276
582	582	277
583	583	278
584	584	279
585	585	280 HB557 INTRODUCED
586	586	Page 11
587	587	review of a coverage determination by the utilization review
588	588	agent. The appeal procedure shall provide for the following:
589	589	a. On appeal, all coverage determinations not to
590	590	certify anto deny a treatment, admission, service, or
591	591	procedure, or medications as being medically necessary or
592	592	appropriate shall be made by a physician in the same or a
593	593	similar general specialty as typically manages the medical
594	594	condition, procedure, or treatment under discussion as
595	595	mutually deemed appropriate. A chiropractor mustshall review
596	596	all cases in which the utilization review organization has
597	597	concluded that a determination not to certify a chiropractic
598	598	service or procedure is appropriate and an appeal has been
599	599	made by the attending chiropractor, enrollee, or designee.
600	600	b. Utilization review agents shall complete the
601	601	adjudication of appeals of determinations not to certify
602	602	admissions, services, and procedures a treatment, admission,
603	603	service, procedure, or medication no later than 30five
604	604	business days in the case of a request for nonurgent care, or
605	605	no later than 24 hours in the case of a request for urgent
606	606	care, from the date the appeal is filed and the receipt of all
607	607	information necessary to complete the appeal.
608	608	c. When an initial determination not to certify a
609	609	health care service is made prior to or during an ongoing
610	610	service requiring review, and the attending physician believes
611	611	that the determination warrants immediate appeal, the
612	612	attending physician shall have an opportunity to appeal that
613	613	determination over the telephone on an expedited basis. A
614	614	representative of a hospital or other health care provider or
615	615	a representative of the enrollee or covered patient may assist
616	616	281
617	617	282
618	618	283
619	619	284
620	620	285
621	621	286
622	622	287
623	623	288
624	624	289
625	625	290
626	626	291
627	627	292
628	628	293
629	629	294
630	630	295
631	631	296
632	632	297
633	633	298
634	634	299
635	635	300
636	636	301
637	637	302
638	638	303
639	639	304
640	640	305
641	641	306
642	642	307
643	643	308 HB557 INTRODUCED
644	644	Page 12
645	645	a representative of the enrollee or covered patient may assist
646	646	in an appeal. Utilization review agents shall complete the
647	647	adjudication on an expedited basis. Utilization review agents
648	648	shall complete the adjudication of expedited appeals within 48
649	649	hours of the date the appeal is filed and the receipt of all
650	650	information necessary to complete the appeal. Expedited
651	651	appeals that do not resolve a difference of opinion may be
652	652	resubmitted through the standard appeal process A determination
653	653	to deny coverage of a treatment, admission, service,
654	654	procedure, or medication is deemed reversed, with coverage
655	655	granted, when a utilization review agent receives all
656	656	information necessary to complete the appeal but does not
657	657	complete the adjudication within the time period that applies
658	658	to a request for nonurgent care or a request for urgent care
659	659	as required in paragraph b .
660	660	(7) Utilization review agents shall maintain an
661	661	electronic portal to communicate with providers and to receive
662	662	and respond to coverage determination or prior authorization
663	663	requests.
664	664	(5)(8) Utilization review agents shall make staff
665	665	available by toll-free telephone at least 4055 hours per week
666	666	duringthat include normal business hours.
667	667	(6)(9) Utilization review agents shall have a telephone
668	668	system capable of accepting or recording incoming telephone
669	669	calls during other than normal business hours and shall
670	670	respond to theseall calls or electronic mail within two
671	671	workingbusiness days.
672	672	(7)(10) Utilization review agents shall comply with all
673	673	applicable laws to protect the confidentiality of individual
674	674	309
675	675	310
676	676	311
677	677	312
678	678	313
679	679	314
680	680	315
681	681	316
682	682	317
683	683	318
684	684	319
685	685	320
686	686	321
687	687	322
688	688	323
689	689	324
690	690	325
691	691	326
692	692	327
693	693	328
694	694	329
695	695	330
696	696	331
697	697	332
698	698	333
699	699	334
700	700	335
701	701	336 HB557 INTRODUCED
702	702	Page 13
703	703	applicable laws to protect the confidentiality of individual
704	704	medical records, including the federal Health Insurance
705	705	Portability and Accountability Act (HIPAA), 42 U.S.C. § 1320d
706	706	et seq.
707	707	(8)(11) Physicians, chiropractors, or psychologists and
708	708	other health care professionals who makingreview utilization
709	709	review determinations and who would require an occupational
710	710	license to practice their profession in the State of Alabama
711	711	shall have current licenses from aan applicable state
712	712	licensing board agency in the United States .
713	713	(9)(12) Utilization review agents shall allow a minimum
714	714	of 24 hours after an emergency treatment, admission, service,
715	715	or procedure for an enrollee or representative of the enrollee
716	716	to notify the utilization review agent and request
717	717	certification or continuing treatment a coverage determination
718	718	for that condition .
719	719	(13) Utilization review agents shall make their
720	720	policies and guidelines easily accessible to enrollees and
721	721	providers in electronic format.
722	722	(14) Utilization review agents shall make coverage
723	723	determinations that are consistent with the provisions of the
724	724	health benefit contract, and policies and guidelines that may
725	725	apply to an enrollee's clinical condition.
726	726	(15) A utilization review agent shall ensure that all
727	727	coverage determinations are reviewed by a physician or other
728	728	health care professional who is competent to evaluate and
729	729	reject, if appropriate, any recommendation or conclusion of
730	730	artificial intelligence that is in conflict with independent
731	731	professional judgment as informed by an enrollee's unique
732	732	337
733	733	338
734	734	339
735	735	340
736	736	341
737	737	342
738	738	343
739	739	344
740	740	345
741	741	346
742	742	347
743	743	348
744	744	349
745	745	350
746	746	351
747	747	352
748	748	353
749	749	354
750	750	355
751	751	356
752	752	357
753	753	358
754	754	359
755	755	360
756	756	361
757	757	362
758	758	363
759	759	364 HB557 INTRODUCED
760	760	Page 14
761	761	professional judgment as informed by an enrollee's unique
762	762	clinical condition, the recommendation of the provider, and
763	763	any applicable policies and guidelines .
764	764	(b) Any utilization review agent that has received
765	765	accreditation by the utilization review accreditation
766	766	commission shall be exempt from this section ."
767	767	"§27-3A-6
768	768	(a) The commissioner shall establish an ombudsman
769	769	program to receive and investigate complaints from enrollees
770	770	or providers aggrieved by a coverage determination by a
771	771	utilization review agent.
772	772	(b) An ombudsman may do any of the following:
773	773	(1) Help an aggrieved enrollee or provider use the
774	774	utilization review agent's internal appeal process for seeking
775	775	a reversal or modification of a coverage denial.
776	776	(2) Help an aggrieved enrollee or provider understand
777	777	provisions of a health benefit plan or the utilization review
778	778	agent's policies and guidelines that may be relevant to a
779	779	claim, or correspondence received from a utilization review
780	780	agent.
781	781	(3) Based on complaints received, investigate any
782	782	general business pattern or practice by a utilization review
783	783	agent that indicates that coverage denials are being made
784	784	contrary to the requirements imposed pursuant to Sections
785	785	27-3A-5(13) through (15).
786	786	(4) Audit compliance by a utilization review agent with
787	787	the coverage provisions of a health benefit plan, its policies
788	788	and guidelines, and the requirements of this chapter, and
789	789	issue a report with findings.
790	790	365
791	791	366
792	792	367
793	793	368
794	794	369
795	795	370
796	796	371
797	797	372
798	798	373
799	799	374
800	800	375
801	801	376
802	802	377
803	803	378
804	804	379
805	805	380
806	806	381
807	807	382
808	808	383
809	809	384
810	810	385
811	811	386
812	812	387
813	813	388
814	814	389
815	815	390
816	816	391
817	817	392 HB557 INTRODUCED
818	818	Page 15
819	819	issue a report with findings.
820	820	(5) Refer a utilization review agent to the department
821	821	for action pursuant to subsection (c).
822	822	(c)(1) Whenever the department has reason to believe
823	823	that a utilization review agent subject to this chapter has
824	824	been or is engaged in conduct that violates this chapter, the
825	825	department shall notify the utilization review agent of the
826	826	alleged violation. The agent shall respond to the notice not
827	827	later than 30 days after the notice is made.
828	828	(b)(2)Upon receiving a response from the utilization
829	829	review agent, Ifif the department finds the response to be
830	830	unsatisfactory or that the utilization review agent has
831	831	violated this chapter, or that the alleged violation has not
832	832	been corrected, the department may conduct a contested case
833	833	hearing on the alleged violation in accordance with the
834	834	Administrative Procedure Act commissioner may hold a hearing as
835	835	provided in Article 1, Chapter 2 .
836	836	(c)(3) If, after the hearing, the department determines
837	837	that the utilization review agent has engaged in a violation,
838	838	the department shall reduce the findings to writing and shall
839	839	issue and cause to be served upon the agent a copy of the
840	840	findings and an order requiring the agent to cease and desist
841	841	from engaging in the violation.
842	842	(d)(4) The department may also exercise either or both
843	843	of the following disciplinary powers:
844	844	(1)a. Impose an administrative fine of not more than
845	845	one thousand dollars ($1,000) for a violation, or not more
846	846	thanfiveten thousand dollars ($5,000)($10,000) for a
847	847	violation that occurred with such frequency as to indicate a
848	848	393
849	849	394
850	850	395
851	851	396
852	852	397
853	853	398
854	854	399
855	855	400
856	856	401
857	857	402
858	858	403
859	859	404
860	860	405
861	861	406
862	862	407
863	863	408
864	864	409
865	865	410
866	866	411
867	867	412
868	868	413
869	869	414
870	870	415
871	871	416
872	872	417
873	873	418
874	874	419
875	875	420 HB557 INTRODUCED
876	876	Page 16
877	877	violation that occurred with such frequency as to indicate a
878	878	general business pattern or practice.
879	879	(2)b. Suspend or revoke the certification of a
880	880	utilization review agent if the agent knew the act was in
881	881	violation of this chapter and repeated the act with such
882	882	frequency as to indicate a general business pattern or
883	883	practice."
884	884	Section 2. Section 27-3A-7 is added to the Code of
885	885	Alabama 1975, to read as follows:
886	886	§27-3A-7
887	887	Nothing in this chapter shall be construed to prohibit
888	888	an enrollee from pursuing any available remedies, including
889	889	civil damages, in an appropriate forum as a consequence of the
890	890	determination, act, or omission of a utilization review agent,
891	891	consistent with other state and federal law.
892	892	Section 3. This act shall become effective on October
893	893	1, 2025.
894	894	421
895	895	422
896	896	423
897	897	424
898	898	425
899	899	426
900	900	427
901	901	428
902	902	429
903	903	430
904	904	431
905	905	432
906	906	433
907	907	434
908	908	435
909	909	436