Stricken language would be deleted from and underlined language would be added to present law.
Act 575 of the Regular Session
*ANS167* 03-16-2023 15:14:00 ANS167
State of Arkansas As Engrossed: H3/6/23 H3/9/23 S3/16/23 1
94th General Assembly A Bill 2
Regular Session, 2023 HOUSE BILL 1271 3
4
By: Representatives L. Johnson, Achor, F. Allen, Bentley, Breaux, K. Brown, M. Brown, Joey Carr, 5
Cavenaugh, Duffield, Ennett, Eubanks, D. Ferguson, V. Flowers, D. Garner, Gramlich, Hawk, G. 6
Hodges, Hollowell, Ladyman, Long, J. Mayberry, McAlindon, McGrew, B. McKenzie, S. Meeks, J. 7
Moore, Painter, Pilkington, J. Richardson, R. Scott Richardson, Richmond, Rye, Underwood, Vaught, 8
Wardlaw, D. Whitaker, Womack, Wooten 9
By: Senators Irvin, J. Boyd 10
11
For An Act To Be Entitled 12
AN ACT TO AMEND THE PRIOR AUTHORIZATION TRANSPARENCY 13
ACT; TO EXEMPT CERTA IN HEALTHCARE PROVID ERS THAT 14
PROVIDE CERTAIN HEAL THCARE SERVICES FROM PRIOR 15
AUTHORIZATION REQUIR EMENTS; AND FOR OTHE R PURPOSES. 16
17
18
Subtitle 19
TO AMEND THE PRIOR AUTHORIZATION 20
TRANSPARENCY ACT; AND TO EXEMPT CERTAIN 21
HEALTHCARE PROVIDERS THAT PROVIDE CERTAIN 22
HEALTHCARE SERVICES FROM PRIOR 23
AUTHORIZATION REQUIREMENTS. 24
25
26
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF ARKANSAS: 27
28
SECTION 1. Arkansas Code § 23-99-1103(8), concerning the definition of 29
"healthcare insurer" under the Prior Authorization Transparency Act, is 30
amended to read as follows: 31
(8)(A)(i) “Healthcare insurer” means an entity that is subject 32
to state insurance regulation, including an insurance company, a health 33
maintenance organization, a hospital and medical service corporation, a risk-34
based provider organization, and a sponsor of a nonfederal self-funded 35
governmental plan. 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
2 03-16-2023 15:14:00 ANS167
(ii) “Healthcare insurer” includes Medicaid where 1
specifically referenced in §§ 23-99-1119 — 23-99-1126. 2
(B) “Healthcare insurer” does not include: 3
(i) A workers' compensation plan; 4
(ii) Medicaid, except as provided under §§ 23-99-5
1119 — 23-99-1126 or when Medicaid services are managed or reimbursed by a 6
healthcare insurer; or 7
(iii) An entity that provides only dental benefits 8
or eye and vision care benefits; 9
10
SECTION 2. Arkansas Code § 23 -99-1103, concerning definitions used 11
under the Prior Authorization Transparency Act, is amended to add ad ditional 12
subdivisions to read as follows: 13
(22) "Random sample" means at least five (5) claims but no more 14
than twenty (20) claims for a particular healthcare service that are selected 15
without method or conscious decision; and 16
(23) "Value-based reimbursement" means reimbursement that: 17
(A) Ties a payment for the provision of healthcare 18
services to the quality of health care provided; 19
(B) Rewards a healthcare provider for efficiency and 20
effectiveness; and 21
(C) May impose a risk -sharing requirement on a healthcare 22
provider for healthcare services that do not meet the healthcare insurer's 23
requirements for quality, effectiveness, and efficiency. 24
25
SECTION 3. Arkansas Code § 23 -99-1104(a)(1), concerning disclosure 26
required under the Prior Au thorization Transparency Act, is amended to read 27
as follows: 28
(a)(1)(A) A utilization review entity shall disclose all of its prior 29
authorization requirements and restrictions, including any written clinical 30
criteria, in a publicly accessible manner on its website. 31
(B) The disclosure under subdivision (a)(1)(A) of this 32
section shall include: 33
(i) A list of any healthcare services that require 34
prior authorization; and 35
(ii) Any written clinical criteria. 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
3 03-16-2023 15:14:00 ANS167
1
SECTION 4. Arkansas Code § 23 -99-1111 is amended to read as follows: 2
23-99-1111. Requests for prior authorization — Qualified persons 3
authorized to review and approve — Adverse determinations to be made only by 4
Arkansas-licensed physicians — Opportunity to discuss treatment before 5
adverse determination . 6
(a) The initial review of information submitted in support of a 7
request for prior authorization may be conducted by a qualified person 8
employed or contracted by a utilization review entity. 9
(b) A request for prior authorization may be approved by a qualified 10
person employed or contracted by a utilization review entity. 11
(c)(1) An adverse determination regarding a request for prior 12
authorization shall be made by a physician who possesses a current and 13
unrestricted license to practice medicine in the State of Arkansas issued by 14
the Arkansas State Medical Board. 15
(2)(A) A utilization review entity shall provide a method by 16
which a physician may request that a prior authorization request be reviewed 17
by a physician in the same specialty as the physician making the request, by 18
a physician in another appropriate specialty, or by a pharmacologist. 19
(B) If a request is made under subdivision (c)(2)(A) of 20
this section, the reviewing physician or pharmacologist is not required to 21
meet the requirements of subdivision (c)(1) of this section. 22
(3)(A) Subject to this subdivision (c)(3), when an adverse 23
determination is issued by a utilization review entity that questions the 24
medical necessity, the appropriateness, or the experimental or 25
investigational nature of a healthcare service, the utilization review entity 26
shall provide in the notice of adverse determination the name and telephone 27
number of a physician who possesses a current and unrestricted license i n 28
this state with whom the requesting healthcare provider may have a reasonable 29
opportunity to discuss the patient's treatment plan and the clinical basis 30
for the intervention. 31
(B) The requesting healthcare provider may contact the 32
reviewing physician at the telephone number provided with the adverse 33
determination under subdivision (c)(3)(A) of this section within one (1) 34
business day of receipt of the adverse determination for an urgent service, 35
or within two (2) business days of receipt of the adverse determination for a 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
4 03-16-2023 15:14:00 ANS167
nonurgent service, to engage in the discussion of the patient's treatment 1
plan and the clinical basis for the intervention under subdivision (c)(3)(A) 2
of this section. 3
(C)(i) Following any discussion under subdivision 4
(c)(3)(B) of this section, the utilization review entity shall notify the 5
healthcare provider whether or not the adverse determination decision remains 6
the same or the service is approved. 7
(ii) The notice under subdivision (c)(3)(C)(i) of 8
this section shall be pro vided: 9
(a) Within one (1) business day of the 10
discussion under subdivision (c)(3)(B) of this section between the provider 11
and physician for an urgent service; or 12
(b) Within two (2) business days of the 13
discussion under subdivision (c)(3)(B) of this section between the provider 14
and physician for a nonurgent service. 15
(D) A discussion under subdivision (c)(3)(A) of this 16
section shall not replace or eliminate the opportunity for any internal 17
grievance or appeal process provided by the utilizatio n review entity. 18
(E) If a requesting healthcare provider is a physician, 19
then the reviewing physician with whom the requesting physician is given an 20
opportunity to discuss the treatment plan and clinical basis for the 21
intervention under subdivision (c)(3)(B) of this section shall be a physician 22
who: 23
(i) Possesses a current and unrestricted 24
license to practice medicine in this state; and 25
(ii) Has the same or similar specialty as the 26
healthcare provider. 27
28
SECTION 5. Arkansas Code Title 23 , Chapter 99, Subchapter 11, is 29
amended to add additional sections to read as follows: 30
23-99-1120. Initial exemption from prior authorization requirements 31
for healthcare providers providing certain healthcare services. 32
(a)(1) Except as provided under s ubdivision (a)(2) of this section, 33
beginning on and after January 1, 2024, a healthcare provider that received 34
approval for ninety percent (90%) or more of the healthcare provider's prior 35
authorization requests based on a review of the healthcare provider' s 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
5 03-16-2023 15:14:00 ANS167
utilization of the particular healthcare services from January 1, 2022, 1
through June 30, 2022, shall not be required to obtain prior authorization 2
for a particular healthcare service and shall be considered exempt from prior 3
authorization requirements th rough September 30, 2024. 4
(2) If a healthcare provider's use for a particular healthcare 5
service increases by twenty -five percent (25%) or more during the period 6
between January 1, 2024, and June 30, 2024, based on a review of the 7
healthcare provider's utilization of the particular healthcare service from 8
January 1, 2022, through June 30, 2022, then the healthcare insurer may 9
disallow the exemption from prior authorization requirements for the 10
healthcare provider for the particular healthcare service. 11
(b)(1) A healthcare insurer shall conduct an evaluation of the initial 12
six-month exemption period based on claims submitted between January 1, 2024, 13
through June 30, 2024, to determine whether to grant or deny an exemption for 14
each particular healthcare service that requires a prior authorization by the 15
healthcare insurer. 16
(2) The evaluation by the healthcare insurer shall be conducted 17
by using the retrospective review process under § 23 -99-1122(c) and applying 18
the criteria under s ubsection (d) of this section. 19
(3) A healthcare insurer shall submit to a healthcare provider a 20
written statement of: 21
(A) The total number of payable claims submitted by or in 22
connection with the healthcare provider; and 23
(B) The total number of denied and approved prior 24
authorizations between January 1, 2022, through June 30, 2022. 25
(c)(1) No later than October 1, 2024, a healthcare insurer shall issue 26
a notice to each healthcare provider that either grants or denies a prior 27
authorization exemption to the healthcare provider for each particular 28
healthcare service. 29
(2) An exemption granted under this subdivision (c)(1) shall be 30
valid for at least twelve (12) months. 31
(d) Except as provided under subsection (f) of this section or § 23 -32
99-1125, a healthcare insurer that uses a prior authorization process for 33
healthcare services shall not require a healthcare provider to obtain prior 34
authorization for a particular health care service that a healthcare provider 35
has previously been subject to a prior authorization requirement if, in the 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
6 03-16-2023 15:14:00 ANS167
most recent six-month evaluation period as described under subsection (e) of 1
this section, the healthcare insurer has approved or would have approved no 2
less than ninety percent (90%) of the prior authorization requests submitted 3
by the healthcare provider for that particular healthcare service. 4
(e)(1) Except as provided under subsection (f) of this section, a 5
healthcare insurer shall evalua te whether or not a healthcare provider 6
qualifies for an exemption from prior authorization requirements under 7
subsection (d) of this section one (1) time every twelve (12) months. 8
(2) The six-month period for the evaluation period described 9
under subsection (d) of this section shall be any consecutive six (6) month 10
period during the twelve (12) months following the effective date of the 11
exemption. 12
(3) The healthcare insurer shall choose a six -month evaluation 13
period that allows time for: 14
(A) The evaluation under subsection (d) of this section; 15
(B) Notice to the healthcare provider of the decision; and 16
(C) Appeal of the decision for an independent review to be 17
completed by the end of the twelve -month period of the exemption. 18
(f) A healthcare insurer may continue an exemption under subsection 19
(d) of this section without evaluating whether or not the healthcare provider 20
qualifies for the exemption under subsection (d) of this section for a 21
particular evaluation period. 22
(g) A healthcare provider is not required to request an exemption 23
under subsection (d) of this section to quality for the exemption. 24
(h) A healthcare insurer may extend an exemption under subsection (d) 25
of this section to a group of healthcare providers under the same tax 26
identification number if: 27
(1) A healthcare provider with an ownership interest in the 28
entity to which the tax identification number is assigned does not object; or 29
(2) The tax identification number is associated with a hospital 30
licensed in this state and the chief executive officer of the hospital agrees 31
to the exemption. 32
33
23-99-1121. Duration of prior authorization exemption. 34
(a) Unless a prior authorization exemption is continued for a longer 35
period of time by a healthcare insurer under § 23-99-1120(f), a healthcare 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
7 03-16-2023 15:14:00 ANS167
provider's exemption from prior authorization requirements under § 23-99-1120 1
remains in effect until the later of: 2
(1) The thirtieth day after the date the healthcare insurer 3
notifies the healthcare provider of the healthcare insurer's determination to 4
rescind the exemption as described under § 23-99-1122, if the healthcare 5
provider does not appeal the healthcare insurer's determination within thirty 6
(30) days of notification of the determination; 7
(2) If the healthcare provider appeals the determination within 8
thirty (30) days of notification of the determination, the fifth day after 9
the date an independent review organization affirms the healthcare insurer's 10
determination to rescind the exemption; or 11
(3) Twelve (12) months after the effective date of the 12
exemption. 13
(b) If a healthcare provider appeals the determination to rescind the 14
exemption more than thirty (30) days after notification of the determination 15
and the independent review organization overturns the rescission, the 16
healthcare provider’s exemption is restored the fifth day after the date of 17
the independent review organization’s decision, and the exemption remains in 18
effect for twelve (12) months after restoration unless rescinded under § 23-19
99-1122. 20
(c) If a healthcare insurer does not finalize a rescission 21
determination as specified in subsection (a) of this section, then the 22
healthcare provider is considered to have met the criteria under § 23-99-1120 23
to continue to qualify for the exemption. 24
(d) A healthcare provider shall not rely on another healthcare 25
provider’s exemption except when the healthcare provider with an exemption is 26
the healthcare provider that orders healthcare services that are rendered by 27
a healthcare provider without an exempti on. 28
29
23-99-1122. Denial or rescission of prior authorization exemption. 30
(a) A healthcare insurer may rescind an exemption from prior 31
authorization requirements of a healthcare provider under § 23-99-1120 only 32
if: 33
(1) The healthcare insurer makes a determination that, on the 34
basis of a retrospective review of a random sample of claims selected by the 35
healthcare insurer during the most recent evaluation period described by § 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
8 03-16-2023 15:14:00 ANS167
23-99-1120(e), less than ninety percent (90%) of the claims for the 1
particular healthcare service met the medical necessity criteria that would 2
have been used by the healthcare insurer when conducting prior authorization 3
review for the particular healthcare service during the relevant evaluation 4
period; 5
(2) The healthcare insurer complies with other applicable 6
requirements specified in this section, including without limitation: 7
(A) Notifying the healthcare provider no less than twenty-8
five (25) days before the proposed rescission is to take effect; and 9
(B) Providing: 10
(i) An identification of the healthcare service that 11
an exemption is being rescinded, the date the notice is issued, and the 12
effective date of the rescission; 13
(ii) A plain-language explanation of how the 14
healthcare provider may appeal and seek an ind ependent review of the 15
determination, the date the notice is issued, and the company’s address and 16
contact information for returning the form by mail or email to request an 17
appeal; 18
(iii) A statement of the total number of payable 19
claims submitted by or in connection with the healthcare provider during the 20
most recent evaluation period that were eligible to be evaluated with respect 21
to the healthcare service subject to rescission, the number of claims 22
included in the random sample, and the sample infor mation used to make the 23
determination, including without limitation: 24
(a) Identification of each claim included in 25
the random sample; 26
(b) The healthcare insurer’s determination of 27
whether each claim met the healthcare insurer’s screening criteri a; and 28
(c) For any claim determined to not have met 29
the healthcare insurer’s screening criteria: 30
(1) The principal reasons for the 31
determination that the claim did not meet the healthcare insurer’s screening 32
criteria, including, if applicable, a statement that the determination was 33
based on a failure to submit specified medical records; 34
(2) The clinical basis for the 35
determination that the claim did not meet the healthcare insurer’s screening 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
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criteria; 1
(3) A description of the sou rces of the 2
screening criteria that were used as guidelines in making the determination; 3
and 4
(4) The professional specialty of the 5
healthcare provider who made the determination; 6
(iv) A space to be filled out by the healthcare 7
provider that includes: 8
(a) The name, address, contact information, 9
and identification number of the healthcare provider requesting an 10
independent review; 11
(b) An indication of whether or not the 12
healthcare provider is requesting that the entity performing the i ndependent 13
review examine the same random sample or a different random sample of claims, 14
if available; and 15
(c) The date the appeal is being requested; 16
and 17
(v) An instruction to the healthcare provider to 18
return the form to the healthcare insurer before the date the rescission 19
becomes effective; and 20
(3) The healthcare provider performs five (5) or fewer of a 21
particular healthcare service in the most recent six -month evaluation period 22
under § 23-99-1120(e). 23
(b) A determination made under subdivision (a)(1) of this section 24
shall be made by a physician who: 25
(1) Possesses a current and unrestricted license to practice 26
medicine in this state; and 27
(2) Has the same or similar specialty as the healthcare 28
provider. 29
(c)(1) A healthcare insurer that is conducting an evaluation under 30
subsection (a) of this section to determine whether or not a healthcare 31
provider still qualifies for a prior authorization exemption may request 32
medical records and documents required for the retrospective review, lim ited 33
to no more than twenty (20) claims for a particular healthcare service. 34
(2) A healthcare insurer shall provide a healthcare provider at 35
least thirty (30) days to provide the medical records requested under 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
10 03-16-2023 15:14:00 ANS167
subdivision (c)(1) of this section. 1
(d) A healthcare insurer may deny an exemption from prior 2
authorization requirements under § 23-99-1120 only if: 3
(1) The healthcare provider does not have an exemption at the 4
time of the relevant evaluation period; and 5
(2) The healthcare insurer provides the healthcare provider 6
with: 7
(A) Actual data for the relevant prior authorization 8
request evaluation period; and 9
(B) Detailed information sufficient to demonstrate that 10
the healthcare provider does not meet the criteria for an exemption from 11
prior authorization requirements for the particular healthcare service under 12
§ 23-99-1120. 13
(e) A healthcare insurer shall: 14
(1) Allow a healthcare provider to designate an email address or 15
a mailing address for communications regarding exemptions, denials, and 16
rescissions; 17
(2) Provide an option for a healthcare provider to submit a 18
request for an appeal by mail, by email, or by other electronic method; and 19
(3) Include an explanation of how a healthcare provider may 20
update his or her preferred contact information and delivery method on the 21
healthcare insurer's website and for all communications issued under this 22
section. 23
24
23-99-1123. Independent review of exemption determination. 25
(a)(1) A healthcare provider has a right to a review of an adverse 26
determination regarding a prior authorization exemption within twelve (12) 27
months of receiving proper notice of recission from a healthcare insurer to 28
be conducted by an independent review organization. 29
(2) A healthcare insurer shall not require a healthcare provider 30
to engage in an internal appeal process before requesting a review by an 31
independent review organization under this section. 32
(3) A healthcare provider who has an exemption rescinded due to 33
a failure to provide medical records within sixty (60) days of a record 34
request for a retrospective review shall not be eligible for review of that 35
rescission by an independent review entity. 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
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(b) A healthcare insurer shall pay: 1
(1) For any appeal or independent review of an adverse 2
determination regarding a prior authorization exemption requested under this 3
section; and 4
(2) A reasonable fee determined by the Arkansas State Medical 5
Board for any copies of medical records or other documents requested from a 6
healthcare provider during an exemption rescission review requested under 7
this section. 8
(c) An independent review organization shall complete an expedited 9
review of an adverse determination regarding a prior authorization exemption 10
no later than the thirtieth day after the date a healthcare provider files 11
the request for a review under this section. 12
(d)(1) A healthcare provider may request that the independent review 13
organization consider another random sample of no fewer than five (5) and no 14
more than twenty (20) claims submitted to the healthcare insurer by the 15
healthcare provider during the relevant evaluation period for the relevant 16
healthcare service as part of the review under this section. 17
(2) If a healthcare provider makes a request under subdivision 18
(d)(1) of this section, the independent review organization shall base its 19
determination on the medical necessity of claims reviewed: 20
(A) By the healthcare insurer under § 23-99-1122; and 21
(B) By the independent review organization under 22
subdivision (d)(1) of this section. 23
(e) The Insurance Commissioner may refuse, suspend, revoke, or not 24
renew a license or certificate of authority of a healthcare insurer that has 25
fifty percent (50%) of healthcare provider appeals overturned in a twelve -26
month period by an independent review organization under this section. 27
28
23-99-1124. Effect of appeal of independent review organization 29
determination. 30
(a) A healthcare insurer is bound by an appeal or independent review 31
organization determination that does not affirm the determination made by the 32
healthcare insurer to rescind a prior authorization exemption. 33
(b) A healthcare insurer shall not retroactively deny a healthcare 34
service on the basis of a rescission of an exemption, even if the healthcare 35
insurer's determination to rescind the prior authorization exemption is 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
12 03-16-2023 15:14:00 ANS167
affirmed by an independent review organization. 1
(c) If a determination of a prior authorization exemption made by the 2
healthcare insurer is overturned on review by an independent review 3
organization, the healthcare insurer: 4
(1) Shall not attempt to rescind the exemption before the end of 5
the next evaluation period; and 6
(2) May only rescind the exemption if the healthcare insurer 7
complies with §§ 23-99-1122 and 23-99-1123. 8
9
23-99-1125. Eligibility for prior authorization exemption following 10
finalized exemption rescission or denial. 11
(a) After a final determination or review affirming the rescission or 12
denial of an exemption for a specific healthcare service under § 23-99-1120, 13
a healthcare insurer shall conduct another evaluation to determine whether or 14
not the exemption should be granted or reinstated based on the six-month 15
evaluation period that follows the evaluation period that formed the basis of 16
the rescission or denial of an exemption. 17
(b) A time period that is included in a previous evaluation or 18
determination period shall not be included in a subsequent evaluation period. 19
20
23-99-1126. Effect of prior authorization exemption. 21
(a) A healthcare insurer shall not deny or reduce payment to a 22
healthcare provider for a healthcare service for which the healthcare 23
provider has qualified for an exemption from prior authorization requirements 24
under § 23-99-1120, including a healthcare service performed or supervised by 25
another healthcare provider, if the health care provider who ordered the 26
healthcare service received a prior authorization exemption based on medical 27
necessity or appropriateness of care unless the healthcare provider: 28
(1) Knowingly and materially misrepresented the healthcare 29
service in a request for payment submitted to the healthcare insurer with the 30
specific intent to deceive the healthcare insurer and obtain an unlawful 31
payment from the healthcare insurer; or 32
(2) Substantially failed to perform the healthcare service. 33
(b) A healthcare insurer shall not conduct a retrospective review of a 34
healthcare service subject to an exemption except: 35
(1) To determine if the healthcare provider still qualifies for 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
13 03-16-2023 15:14:00 ANS167
an exemption under § 23 -99-1120; or 1
(2) If the healthcare insur er has a reasonable cause to suspect 2
a basis for denial exists under subsection (a) of this section. 3
(c) For a retrospective review described by subdivision (b)(2) of this 4
section, §§ 23-99-1120 — 23-99-1125 shall not modify or otherwise affect: 5
(1) The requirements under or application of § 23-99-1115, 6
including without limitation any time frames; or 7
(2) Any other applicable law, except to prescribe the only 8
circumstances under which: 9
(A) A retrospective review may occur as specified by 10
subdivision (b)(2) of this section; or 11
(B) Payment may be denied or reduced as specified by 12
subsection (a) of this section. 13
(d) Beginning on January 1, 2024, a healthcare insurer shall provide 14
to a healthcare provider a notice that includes a: 15
(1) Statement that the healthcare provider has an exemption from 16
prior authorization requirements under § 23-99-1120; 17
(2) List of the healthcare services and health benefit plans to 18
which the exemption applies; and 19
(3) Statement of the duration of the exemption. 20
(e) If a healthcare provider submits a prior authorization request for 21
a healthcare service for which the healthcare provider has an exemption from 22
prior authorization requirements under § 23-99-1120, the healthcare insurer 23
shall promptly provide a notice to the healthcare provider that includes: 24
(1) The information described in subsection (d) of this section; 25
and 26
(2) A notification of the healthcare insurer's payment 27
requirements. 28
(f) This section and §§ 23-99-1120 — 23-99-1125 shall not be construed 29
to: 30
(1) Authorize a healthcare provider to provide a healthcare 31
service outside the scope of the healthcare provider's applicable license; or 32
(2) Require a healthcare insurer to pay for a healthcare service 33
described by subdivision (f)(1) of this section that is performed in 34
violation of the laws of this state. 35
(g) A healthcare insurer that offers multiple health benefit plans or 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
14 03-16-2023 15:14:00 ANS167
that utilizes multiple healthcare provider networks shall not determine a 1
healthcare provider’s eligibility for an exemption from prior authorization 2
for each specific health benefit plan or each specific healthcare provider 3
network but rather shall determine the healthcare provider’s eligibility for 4
an exemption applicable to all health benefit plans and healthcar e provider 5
networks. 6
(h) If a healthcare insurer and a healthcare provider are engaged in a 7
value-based reimbursement arrangement for particular healthcare services or 8
subscribers, the healthcare insurer shall not impose any prior authorization 9
requirements for any particular healthcare service that is included in that 10
value-based reimbursement arrangement. 11
12
23-99-1127. Applicability. 13
(a)(1) An organization or entity directly or indirectly providing a 14
plan or services to patients under the Medicaid Provider -Led Organized Care 15
Act, § 20-77-2701 et seq., or any other Medicaid -managed care program 16
operating in this state is exempt from §§ 23 -99-1120 – 23-99-1126 if the 17
program, without limiting the program's application to any other plan or 18
program, develops a program to reduce or eliminate prior authorizations for a 19
healthcare provider on or before January 1, 2025. 20
(2) The Arkansas Health and Opportunity for Me Program established by 21
the Arkansas Health and Opportunity for Me Act of 2021, § 23 -61-1001 et seq., 22
or its successor program is exempt from §§ 23 -99-1120 – 23-99-1126, provided 23
that the Arkansas Health and Opportuni ty for Me Program, without limiting the 24
Arkansas Health and Opportunity for Me Program's application to any other 25
plan or program, develops a program to reduce or eliminate prior 26
authorizations for a healthcare provider on or before January 1, 2025. 27
(3) A qualified health plan that is a health benefit plan under 28
the Patient Protection and Affordable Care Act, Pub. L. No. 111 -148, and 29
purchased on the Arkansas Health Insurance Marketplace created under the 30
Arkansas Health Insurance Marketplace Act, § 23-61-801 et seq., for an 31
individual up to four hundred percent (400%) of the federal poverty level, 32
operating in this state is exempt from §§ 23-99-1120 — 23-99-1126 if the 33
qualified health plan, without limiting the program's application to any 34
other plan or program, develops a program to reduce or eliminate prior 35
authorizations for a healthcare provider on or before January 1, 2025. 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
15 03-16-2023 15:14:00 ANS167
(b)(1) The programs under subsection (a) of this section to reduce or 1
eliminate prior authorization shall be: 2
(A) Submitted to the State Insurance Department; and 3
(B) Subject to approval by the Legislative Council. 4
(2) If a program is not submitted to the department and approved 5
by the Legislative Council on or before January 1, 2025, the Medicaid -managed 6
care program operating in this state, the Arkansas Health and Opportunity for 7
Me Program established by the Arkansas Health and Opportunity for Me Act of 8
2021, § 23-61-1001 et seq., or its successor program, and qualified health 9
plans under the Patient Protection and Affordable Care Act, Pub. L. No. 111 -10
148, and purchased on the Arkansas Health Insurance Marketplace created under 11
the Arkansas Health Insurance Marketplace Act, § 23-61-801 et seq., for an 12
individual up to four hundred percent (400%) of the federal povert y level, 13
operating in this state shall be subject to §§ 23 -99-1120 – 23-99-1126 and § 14
23-99-1128 as of January 1, 2025. 15
(c) Any state or local governmental employee plan is exempt from §§ 16
23-99-1120 — 23-99-1126 and § 23-99-1128. 17
(d) A health benefit p lan provided by a trust established under §§ 14 -18
54-101 and 25-20-104 to provide benefits, including accident and health 19
benefits, death benefits, dental benefits, and disability income benefits, is 20
exempt from §§ 23-99-1120 – 23-99-1126. 21
(e)(1) Prescription drugs, medicines, biological products, 22
pharmaceuticals, or pharmaceutical services are exempt as a healthcare 23
service for purposes of §§ 23 -99-1120 – 23-99-1126 until December 31, 2024. 24
(2)(A) As of January 1, 2025, the provisions of §§ 23 -99-1120 – 25
23-99-1126 shall apply to prescription drugs, medicines, biological products, 26
pharmaceuticals, or pharmaceutical services that have not been approved for 27
continuation of prior authorization under § 23 -99-1128. 28
(B) For the products in subdivision (e)(2)(A) of this 29
section that have not been approved for continuation of prior authorization, 30
for purposes of § 23 -99-1120, then: 31
(i) Provisions regarding time periods specified 32
during the calendar year 2022 shall instead apply to the same months dur ing 33
calendar year 2023; and 34
(ii) Provisions regarding time periods specified 35
during the calendar year 2024 shall instead apply to the same months during 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
16 03-16-2023 15:14:00 ANS167
calendar year 2025. 1
2
23-99-1128. Prescription drugs, medicines, biological products, 3
pharmaceuticals, or pharmaceutical services. 4
(a)(1) Beginning on January 1, 2024, a healthcare insurer or pharmacy 5
benefits manager shall submit a written request to the Arkansas State Board 6
of Pharmacy for any prescription drug, medicine, biological product, 7
pharmaceutical, or pharmaceutical service to be reviewed for a continuation 8
of prior authorization by a specified health benefit plan whether or not a 9
healthcare provider has met the criteria for an exemption from prior 10
authorization under §§ 23 -99-1120 – 23-99-1126. 11
(2) The request under subdivision (a)(1) of this section shall 12
state the reason the request is being made for each prescription drug, 13
medicine, biological product, pharmaceutical, or pharmaceutical service for 14
the specified health benefit plan. 15
(b) The Arkansas State Board of Pharmacy and the Arkansas State 16
Medical Board, jointly, may establish criteria and procedures to review 17
whether a request made under subdivision (a)(1) of this section should be 18
granted for the requesting party and specifi ed health benefit plan. 19
(c)(1) The Arkansas State Board of Pharmacy and the Arkansas State 20
Medical Board, jointly, may determine whether or not a prescription drug, 21
medicine, biological product, pharmaceutical, or pharmaceutical service may 22
be subject to prior authorization by a health benefit plan under the criteria 23
and procedures under subsection (b) of this section. 24
(2) The Arkansas State Board of Pharmacy shall promptly notify 25
the entity that made the request of the joint decision made by the Arkan sas 26
State Board of Pharmacy and the Arkansas State Medical Board. 27
(d) The Arkansas State Board of Pharmacy shall make available to any 28
person who requests it, a list for any health benefit plan of prescription 29
drugs, medicines, biological products, pharmaceuticals, or pharmaceutical 30
services that require a prior authorization under this section. 31
32
23-99-1129. Appeals process for disallowance of prior authorization. 33
(a) If the Arkansas State Board of Pharmacy and the Arkansas State 34
Medical Board, jointly, disallow a prior authorization of a prescription 35
drug, medicine, biological product, pharmaceutical, or pharmaceutical service 36 As Engrossed: H3/6/23 H3/9/23 S3/16/23 HB1271
17 03-16-2023 15:14:00 ANS167
requested under § 23 -99-1128, a healthcare insurer, pharmacy benefits 1
manager, or other interested party may file an app eal to the State Insurance 2
Department within ninety (90) days of the disallowance of the prior 3
authorization. 4
(b) No later than the thirtieth day after the date a healthcare 5
insurer, pharmacy benefits manager, or other interested party files an appeal 6
under subsection (a) of this section, the Insurance Commissioner shall 7
appoint an independent review organization to review the appeal. 8
(c) A healthcare insurer, pharmacy benefits manager, or other 9
interested party that files an appeal under subsection (a) of this section 10
shall pay for the independent review organization appointed under subsection 11
(b) of this section to review the appeal. 12
(d) A healthcare insurer, pharmacy benefits manager, or other 13
interested party is bound by the independent review organization's 14
determination of the appeal under this section. 15
16
/s/L. Johnson 17
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APPROVED: 4/11/23 20
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