Stricken language would be deleted from and underlined language would be added to present law.
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State of Arkansas 1
95th General Assembly A Bill 2
Regular Session, 2025 HOUSE BILL 1301 3
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By: Representative L. Johnson 5
By: Senator Irvin 6
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For An Act To Be Entitled 8
AN ACT TO AMEND THE PRIOR AUTHORIZATION TRANSPARENCY 9
ACT; AND FOR OTHER PURPOSES. 10
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Subtitle 13
TO AMEND THE PRIOR AUTHORIZATION 14
TRANSPARENCY ACT. 15
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BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF ARKANSAS: 17
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SECTION 1. Arkansas Code § 23 -99-1120 is amended to read as follows: 19
23-99-1120. Initial exemption from prior authorization requirements 20
for healthcare providers providing certain healthcare services. 21
(a)(1) Except as provided under subdivision (a)(2) of this section, 22
beginning on and after January 1, 2024, a healthcare provider that received 23
approval for ninety percent (90%) or more of the healthcare provider's prior 24
authorization requests based on a review of the healthcare provider's 25
utilization of the particular healthcare services from January 1, 2022, 26
through June 30, 2022, shall not be required to obtain prior authorization 27
for a particular healthcare service and shall be considered exempt from prior 28
authorization requirements through September 30, 2024. 29
(2) If a healthcare provider's use for a particular healthcare 30
service increases by twenty -five percent (25%) or more during the period 31
between January 1, 2024, and June 30, 2024, based on a review of the 32
healthcare provider's utilization of the particular healthcare service from 33
January 1, 2022, through June 30, 2022, then the healthcare insurer may 34
disallow the exemption from prior authorization requirements for the 35
healthcare provider for the particular healthcare service. 36 HB1301
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(b)(1) A healthcare insurer shall conduct an evaluation of the initial 1
six-month exemption period based on claims submitted between January 1, 2024, 2
through June 30, 2024, to determine whether to grant or deny an exemption for 3
each particular healthcare service that requires a prior authorization by the 4
healthcare insurer. 5
(2) The evaluation by the healthcare insurer shall be conducted 6
by using the retrospective review process under § 23 -99-1122(c) and applying 7
the criteria under subsection (d) of this section. 8
(3) A healthcare insurer shall submit to a healthcare provider a 9
written statement of: 10
(A) The total number of payable claims submitted by or in 11
connection with the healthcare provider; and 12
(B) The total number of denied and approved prior 13
authorizations between January 1, 2022, through June 30, 2022. 14
(c)(1) No later than October 1, 2024, a healthcare insurer shall issue 15
a notice to each healthcare provider that either grants or denies a prior 16
authorization exemption to the healthcare provider for each particular 17
healthcare service. 18
(2) An exemption granted under this subdivision (c)(1) shall be 19
valid for at least twelve (12) months. 20
(d) Except as provided under subsection (f) subsection (c) of this 21
section or § 23-99-1125, a healthcare insurer that uses a prior authorization 22
process for healthcare services shall not require a healthcare provider to 23
obtain prior authorization for a particular healthcare service that a 24
healthcare provider has previously been subject to a prior authorization 25
requirement if, in the most recent six -month evaluation period as described 26
under subsection (e) subsection (b) of this section, the healthcare insurer 27
has approved or would have approved no less than ninety percent (90%) of the 28
prior authorization requests submitted by the healthcare provider for that 29
particular healthcare service. 30
(e)(1)(b)(1) Except as provided under subsection (f) subsection (c) of 31
this section, a healthcare insurer shall evaluate whether or not a healthcare 32
provider qualifies for an exemption from prior authorization requirements 33
under subsection (d) subsection (a) of this section one (1) time every twelve 34
(12) months. 35
(2) The six-month period for the evaluation period described 36 HB1301
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under subsection (d) subsection (a) of this section shall be : 1
(A) For a healthcare provider with an existing exemption 2
under this section, any consecutive six-month period during the twelve (12) 3
months following the effective date of the exemption ; 4
(B) For an initial healthcare provider, any consecutive 5
six-month period during the twelve (12) months following the healthcare 6
provider's first filed claim with the healthcare insurer; or 7
(C) For an initial healthcare insurer, any consecutive 8
six-month period during the twelve (12) months following the healthcare 9
insurer's commencement of operations subject to this subchapter . 10
(3) The healthcare insurer shall choose a six -month evaluation 11
period that allows time for: 12
(A) The evaluation under subsection (d) subsection (a) of 13
this section; 14
(B) Notice to the healthcare provider of the decision; and 15
(C) Appeal of the decision for an independent review to be 16
completed by the end of the twelve -month period of the exemption. 17
(f)(c) A healthcare insurer may continue an exemption under subsection 18
(d) subsection (a) of this section without evaluating whether or not the 19
healthcare provider qualifies for the exemption under subsection (d) 20
subsection (a) of this section for a particular evaluation period. 21
(g)(d) A healthcare provider is not required to request an exemption 22
under subsection (d) subsection (a) of this section to quality qualify for 23
the exemption. 24
(h)(e)(1) A healthcare insurer may shall extend an exemption under 25
subsection (d) subsection (a) of this section to a group of healthcare 26
providers under the same tax identification number if either the healthcare 27
insurer or the healthcare provider elects to do so, and : 28
(1)(A) A healthcare provider with an ownership interest in 29
the entity to which the tax identification number is assigned does not 30
object; or 31
(2)(B) The tax identification number is associated with a 32
hospital licensed in this state and the chief executive officer of the 33
hospital agrees to the exemption. 34
(2) If a healthcare insurer elects to extend an exemption under 35
subdivision (e)(1) of this section to a group of healthcare providers, the 36 HB1301
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healthcare insurer shall provide to each affected healthcare provider at 1
least sixty (60) days' prior notice of the election and of any modification 2
to or termination of the election. 3
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SECTION 2. Arkansas Code § 23 -99-1121(a), concerning the duration of a 5
prior authorization exemption under the Prior Authorization Transparency Act, 6
is amended to read as follows: 7
(a) Unless a prior authorization exemption is continued for a longer 8
period of time by a healthcare insurer under § 23-99-1120(f) § 23-99-1120(c), 9
a healthcare provider's exemption from prior authorization requirements under 10
§ 23-99-1120 remains in effect until the later of: 11
(1) The thirtieth day after the date the healthcare insurer 12
notifies the healthcare provider of the healthcare insurer's determination to 13
rescind the exemption as described under § 23 -99-1122, if the healthcare 14
provider does not appeal the healthcare insurer's determination within thirty 15
(30) days of notification of the determination; 16
(2) If the healthcare provider appeals the determination within 17
thirty (30) days of notification of the determination, the fifth day after 18
the date an independent review organization affirms the healthcare insurer's 19
determination to rescind the exemption; or 20
(3) Twelve (12) months after the effective date of the 21
exemption. 22
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SECTION 3. Arkansas Code § 23 -99-1122(a), concerning the recission of 24
a prior authorization exemption under the Prior Authorization Transparency 25
Act, is amended to read as follows: 26
(a) A healthcare insurer may rescind an exemption from prior 27
authorization requirements of a healthcare provider under § 23 -99-1120 only 28
if: 29
(1) The healthcare insurer makes a determination that, on the 30
basis of a retrospective review of a random sample of claims selected by the 31
healthcare insurer during the most recent evaluation period described by § 32
23-99-1120(e) § 23-99-1120(b), less than ninety percent (90%) of the claims 33
for the particular healthcare service met the medical necessity criteria that 34
would have been used by the healthcare insurer when conducting prior 35
authorization review for the particular healthcare service during the 36 HB1301
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relevant evaluation period; 1
(2) The healthcare insurer complies with other applicable 2
requirements specified in this section, including without limitation: 3
(A) Notifying the healthcare provider no less than twenty-4
five (25) thirty (30) days before the proposed rescission is to take effect; 5
and 6
(B) Providing: 7
(i) An identification of the healthcare service that 8
an exemption is being rescinded, the date the notice is issued, and the 9
effective date of the rescission; 10
(ii) A plain-language explanation of how the 11
healthcare provider may appeal and seek an independent review of the 12
determination, the date the notice is issued, and the company's address and 13
contact information for returning the form by mail or email to request an 14
appeal; 15
(iii) A statement of the total number of payable 16
claims submitted by or in connection with the healthcare provider during the 17
most recent evaluation period that were eligible to be evaluated with respect 18
to the healthcare service subject to rescission, the number of claims 19
included in the random sample, and the sample information used to make the 20
determination, including without limitation: 21
(a) Identification of each claim included in 22
the random sample; 23
(b) The healthcare insurer's determination of 24
whether each claim met the healthcare insurer's screening criteria; and 25
(c) For any claim determined to not have met 26
the healthcare insurer's screening criteria: 27
(1) The principal reasons for the 28
determination that the claim did not meet the healthcare insurer's screening 29
criteria, including, if applicable, a statement that the determination was 30
based on a failure to submit specified medical records; 31
(2) The clinical basis for the 32
determination that the claim did not meet the healthcare insurer's screening 33
criteria; 34
(3) A description of the sources of the 35
screening criteria that were used as guidelines in making the determination; 36 HB1301
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and 1
(4) The professional specialty of the 2
healthcare provider who made the determination; 3
(iv) A space to be filled out by the healthcare 4
provider that includes: 5
(a) The name, address, contact information, 6
and identification number of the healthcare provider requesting an 7
independent review; 8
(b) An indication of whether or not the 9
healthcare provider is requesting that the entity performing the independent 10
review examine the same random sample or a different random sample of claims, 11
if available; and 12
(c) The date the appeal is being requested; 13
and 14
(v) An instruction to the healthcare provider to 15
return the form to the healthcare insurer before the date the rescission 16
becomes effective; and 17
(3) The healthcare provider performs five (5) or fewer of 18
a particular healthcare service in the most recent six -month evaluation 19
period under § 23-99-1120(e) § 23-99-1120(b). 20
21
SECTION 4. Arkansas Code § 23 -99-1122(c)(2), concerning the timeline a 22
healthcare insurer provides to a healthcare provider to provide medical 23
records under the Prior Authorization Transparency Act, is amended to read as 24
follows: 25
(2) A healthcare insurer shall provide a healthcare provider at 26
least thirty (30) sixty (60) days to provide the medical records requested 27
under subdivision (c)(1) of this section. 28
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SECTION 5. Arkansas Code § 23 -99-1126(a), concerning the payments to a 30
healthcare provider who has an exemption under the Prior Authorization 31
Transparency Act, is amended to read as follows: 32
(a)(1) A healthcare insurer shall not deny or reduce payment to a 33
healthcare provider for a healthcare service for which the healthcare 34
provider has qualified for an exemption from prior authorization requirements 35
under § 23-99-1120, including a healthcare service performed or supervised by 36 HB1301
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another healthcare provider, if the healthcare provider who ordered the 1
healthcare service received a prior authorization exemption based on medical 2
necessity or appropriateness of care unless the healthcare provider: 3
(1)(A) Knowingly and materially misrepresented the 4
healthcare service in a request for payment submitted to the healthcare 5
insurer with the specific intent to deceive the healthcare insurer and obtain 6
an unlawful payment from the healthcare insurer; or 7
(2)(B) Substantially failed to perform the healthcare 8
service. 9
(2)(A) Subdivision (a)(1) of this section does not constitute a 10
basis for a healthcare insurer to: 11
(i) Request information from a healthcare provider; 12
or 13
(ii) Delay reimbursement in order to obtain 14
information. 15
(B) A request for information under subdivision 16
(a)(2)(A)(i) of this section shall comply with applicable laws and rules. 17
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SECTION 6. Arkansas Code § 23 -99-1126(d), concerning the information 19
required in the notice to a healthcare provider under the Prior Authorization 20
Transparency Act, is amended to read as follows: 21
(d) Beginning on January 1, 2024, a A healthcare insurer shall provide 22
to a healthcare provider a notice that includes a: 23
(1) Statement that the healthcare provider has an exemption from 24
prior authorization requirements under § 23 -99-1120; 25
(2) List of the healthcare services and health benefit plans to 26
which the exemption applies; and 27
(3) Statement of the duration of the exemption. 28
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SECTION 7. Arkansas Code § 23 -99-1127 is amended to read as follows: 30
23-99-1127. Applicability. 31
(a)(1) An organization or entity directly or indirectly providing a 32
plan or services to patients under the Medicaid Provider -Led Organized Care 33
Act, § 20-77-2701 et seq., or any other Medicaid -managed care program 34
operating in this state is exempt from §§ 23 -99-1120 — 23-99-1126 if the 35
program, without limiting the program's application to any other plan or 36 HB1301
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program, develops and conforms to a program to reduce or eliminate prior 1
authorizations for a healthcare provider on or before January 1, 2025 . 2
(2) The Arkansas Health and Opportunity for Me Program 3
established by the Arkansas Health and Opportunity for Me Act of 2021, § 23 -4
61-1001 et seq., or its successor program is exempt from §§ 23 -99-1120 — 23-5
99-1126, provided that the Arkansas Health and Opportunity for Me Program, 6
without limiting the Arkansas Health and Opportunity for Me Program's 7
application to any other plan or program, develops and conforms to a program 8
to reduce or eliminate prior authorizations for a healthcare provider on or 9
before January 1, 2025 . 10
(3) A qualified health plan that is a health benefit plan under 11
the Patient Protection and Affordable Care Act, Pub. L. No. 111 -148, and 12
purchased on the Arkansas Health Insurance Marketplace created under the 13
Arkansas Health Insurance Marketplace Act, § 23 -61-801 et seq., for an 14
individual up to four hundred percent (400%) of the federal poverty level, 15
operating in this state is exempt from §§ 23 -99-1120 — 23-99-1126 if the 16
qualified health plan, without limiting the program's application to any 17
other plan or program, develops and conforms to a program to reduce or 18
eliminate prior authorizations for a healthcare provider on or before January 19
1, 2025. 20
(b)(1)(A) The programs At least one (1) time every two (2) years, a 21
program under subsection (a) of this section to reduce or eliminate prior 22
authorization shall be: 23
(A)(i) Submitted to the State Insurance Department; 24
and 25
(B)(ii) Subject to approval by the Legislative 26
Council. 27
(B) A program under subsection (a) of this section shall 28
include: 29
(i) Data, statistics, and other appropriate 30
documentation demonstrating the effectiveness of the previously submitted 31
program in reducing or eliminating prior authorizations for a healthcare 32
provider; and 33
(ii) For a program that does not eliminate prior 34
authorizations for a healthcare provider, specific initiatives or elements of 35
the program that reduce existing prior authorizations for a healthcare 36 HB1301
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provider. 1
(C)(i) Upon submitting the program under subdivision 2
(b)(1) of this section, the submitting entity shall provide notice to each 3
healthcare provider that includes: 4
(a) The complete program submission; 5
(b) The deadline for a healthcare provider to 6
comment on the program submission; and 7
(c) Instructions on how a healthcare provider 8
may comment on the program. 9
(ii) A healthcare provider shall have at least 10
thirty (30) days to comment on a program submitted under subdivision (b)(1) 11
of this section. 12
(2) If a program is not submitted to the department and approved 13
by the Legislative Council on or before January 1, 2025 as required or does 14
not conform to the requirements of this section , the Medicaid-managed care 15
program operating in this state, the Arkansas Health and Opportunity for Me 16
Program established by the Arkansas Health and Opportunity for Me Act of 17
2021, § 23-61-1001 et seq., or its successor program, and qualified health 18
plans under the Patient Protection and Affordable Care Act, Pub. L. No. 111 -19
148, and purchased on the Arkansas Health Insurance Marketplace created under 20
the Arkansas Health Insurance Marketplace Act, § 23 -61-801 et seq., for an 21
individual up to four hundred percent (400%) of the federal poverty level, 22
operating in this state shall be subject to §§ 23 -99-1120 — 23-99-1126 and § 23
23-99-1128 as of January 1, 2025 . 24
(c) Any state or local governmental employee plan is exempt from §§ 25
23-99-1120 — 23-99-1126 and § 23-99-1128. 26
(d) A health benefit plan provided by a trust established under §§ 14 -27
54-101 and 25-20-104 to provide benefits, including accident and health 28
benefits, death benefits, dental benefits, and disability income benefits, is 29
exempt from §§ 23-99-1120 — 23-99-1126. 30
(e)(1) Prescription drugs, medicines, biological products, 31
pharmaceuticals, or pharmaceutical services are exempt as a healthcare 32
service for purposes of §§ 23 -99-1120 — 23-99-1126 until December 31, 2024. 33
(2)(A) As of January 1, 2025, the provisions of §§ 23 -99-1120 — 34
23-99-1126 shall apply to prescription drugs, medicines, biological products, 35
pharmaceuticals, or pharmaceutical services that have not been approved for 36 HB1301
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continuation of prior authorization under § 23 -99-1128. 1
(B) For the products in subdivision (e)(2)(A) of this 2
section that have not been approved for continuation of prior authorization, 3
for purposes of § 23 -99-1120, then: 4
(i) Provisions regarding time periods specified 5
during calendar year 2022 shall instead apply to the same months during 6
calendar year 2023; and 7
(ii) Provisions regarding time periods specified 8
during calendar year 2024 shall instead apply to the same months during 9
calendar year 2025. 10
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SECTION 8. Arkansas Code § 23 -99-1128(a), concerning written requests 12
for prescription drugs, medicines, biological products, pharmaceuticals, or 13
pharmaceutical services under the Prior Authorization Transparency Act, is 14
amended to read as follows: 15
(a)(1)(A) Beginning on January 1, 2024, a A healthcare insurer or 16
pharmacy benefits manager shall submit a written request to the Arkansas 17
State Board of Pharmacy for any prescription drug, medicine, biological 18
product, pharmaceutical, or pharmaceutical service to be reviewed for a 19
continuation or implementation of prior authorization by a specified health 20
benefit plan. 21
(B)(i) whether or not a healthcare provider has met the 22
criteria for an A prescription drug, medicine, biological product, 23
pharmaceutical, or pharmaceutical service approved for continuation or 24
implementation of a prior authorization under this section is not subject to 25
an exemption from prior authorization under §§ 23 -99-1120 — 23-99-1126. 26
(ii) A prescription drug, medicine, biological 27
product, pharmaceutical, or pharmaceutical service approved for continuation 28
or implementation of a prior authorization under this section is subject to 29
an exemption from prior authorization under §§ 23 -99-1120 — 23-99-1126. 30
(2) The request under subdivision (a)(1) subdivision (a)(1)(A) 31
of this section shall state the reason the request is being made for each 32
prescription drug, medicine, biological product, pharmaceutical, or 33
pharmaceutical service for the specified health benefit plan. 34
35
SECTION 9. Arkansas Code § 23 -99-1128, concerning prescription drugs, 36 HB1301
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medicines, biological products, pharmaceuticals, or pharmaceutical services 1
under the Prior Authorization Transparency Act, is amended to add an 2
additional subsection to read as follows: 3
(e) A healthcare insurer shall issue notice to a healthcare provider 4
of a determination made under this section or under § 23 -99-1129 that affects 5
the applicability of the healthcare provider's exemption from prior 6
authorization under §§ 23 -99-1120 — 23-99-1126. 7
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