HB 2175
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ARIZONA HOUSE OF REPRESENTATIVES
Fifty-seventh Legislature
First Regular Session
House: COM DPA 10-0-0-0
HB 2175: claims; prior authorization; conduct
Sponsor: Representative Willoughby, LD 13
Caucus & COW
Overview
Requires a health care provider to review each claim for health care services before denial or
prior authorization.
History
A health care services plan or its utilization review agent may impose a prior authorization
requirement for health care services provided to an enrollee. A prior authorization
requirement is a practice implemented by a health care services plan or its utilization review
agent in which coverage of a health care service is dependent on an enrollee or a provider
obtaining approval from the health care services plan before the service is performed,
received or prescribed, as applicable. If the prior authorization request is denied, the health
care services plan or its utilization review agent shall state the specific reason for the denial.
On a denial of a prior authorization request, the enrollee and the provider may exercise the
review and appeal rights granted under the health care appeals process (A.R.S. §§ 20-3402,
20-3404).
Any direct denial of prior authorization of a service requested by a health care provider on
the basis of medical necessity by a health care insurer must be made in writing by a medical
director who holds an active unrestricted license to practice medicine in this. The written
denial must include an explanation of why the treatment was denied, and the medical
director who made the denial must sign the written denial. The health care insurer must
send a copy of the written denial to the health care provider who requested the treatment
(A.R.S. § 20-2510).
A member who receives an adverse determination may pursue the applicable review process
as prescribed in statute. A health care insurer must provide at least the following levels of
review: 1) an expedited medical review and expedited appeal; 2) an initial appeal; and 3) an
external independent review. A health care insurer must provide a written determination as
and include the basis, criteria used, clinical reasons and rationale for the determination
(A.R.S. § 20-2533).
Provisions
1. Requires a health care provider to individually review each claim for health care services
before a health care insurer denies a claim or a prior authorization unless:
a) the denial is due to a lack of administrative completeness;
b) the member enrollment status is excluded from coverage under the plan; or
c) a determination is made that a service or provider type is categorically excluded from
coverage under the plan. (Sec. 1)
☐ Prop 105 (45 votes) ☐ Prop 108 (40 votes) ☐ Emergency (40 votes) ☐ Fiscal Note HB 2175
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2. Prohibits the use of artificial intelligence to deny a claim or prior authorization. (Sec. 1)
3. Classifies the denial of a claim or a prior authorization without an individual review of
the claim as an act of unprofessional conduct. (Sec. 1)
4. Outlines the health care professionals that are defined as a health care provider. (Sec. 1)
Amendments
Committee on Commerce
1. Removes language outlining the conditions in which a health care provider is not required
to review each claim for health care services.
2. Clarifies that artificial intelligence may not be used to deny a claim or a prior
authorization for medical necessity, experimental status or any other reason that involves
the use of medical judgment.