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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to prior authorization for health care 2
services; amending s. 627.42392, F.S.; providing 3
definitions; deleting the definition of the term 4
"health insurer"; providing a process to accept 5
electronic requests for prior authorization for health 6
care services; providing requirements for the 7
electronic prior authorization process; providing 8
notification requirements for prior authorization 9
determinations; prohibiting requirements for prior 10
authorizations for certain health care services and 11
medications; prohibiting prior authorization 12
revocations, limitations, conditions, and restrictions 13
under a specified circumstance; providing requirements 14
for payments to health care providers; providing 15
length of prior authorization validity under certain 16
circumstances; prohibiting requirements for additional 17
prior authorizations under certain circumstances; 18
providing construction; prohibiting certain provisions 19
from being waived; providing an effective date. 20
21
Be It Enacted by the Legislature of the State of Florida: 22
23
Section 1. Section 627.42392, Florida Statutes, is amended 24
to read: 25
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627.42392 Prior authorization. — 26
(1) As used in this section, the term : 27
(a) "Adverse determination" means a decision by a 28
utilization review entity that the health care services provided 29
or proposed to be provided to an insured are not medically 30
necessary or are experimental or investigational and that 31
benefit coverage is theref ore denied, reduced, or terminated. 32
For purposes of this section, the term does not include a 33
decision to deny, reduce, or terminate services that are not 34
covered for reasons other than their medical necessity or 35
experimental or investigational nature. 36
(b) "Electronic prior authorization process" does not 37
include a transmission through a facsimile machine. 38
(c) "Emergency health care service" has the same meaning 39
as the term "emergency services and care" as defined in s. 40
395.002(9). 41
(d) "Prior authoriz ation" means the process by which a 42
utilization review entity determines the medical necessity or 43
appropriateness of otherwise covered health care services before 44
the provision of such health care services. The term also 45
includes any health insurer's or ut ilization review entity's 46
requirement that an insured or health care provider notify the 47
health insurer or utilization review entity before providing a 48
health care service. 49
(e) "Urgent health care service" means a health care 50
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service with respect to whic h the application of the time 51
periods for making a nonexpedited prior authorization, in the 52
opinion of a physician with knowledge of the patient's medical 53
condition, could: 54
1. Seriously jeopardize the life or health of the patient 55
or the ability of the p atient to regain maximum function; or 56
2. Subject the patient to severe pain that cannot be 57
adequately managed without the care, treatment, or prescription 58
drugs that are the subject of the prior authorization request. 59
(f) "Utilization review entity" "health insurer" means an 60
authorized insurer offering health insurance as defined in s. 61
624.603, a managed care plan as defined in s. 409.962(10), or a 62
health maintenance organization as defined in s. 641.19(12) , a 63
pharmacy benefit manager as defined in s. 6 24.490(1), or any 64
other individual or entity that provides, offers to provide, or 65
administers hospital, outpatient, medical, prescription drug, or 66
other health benefits to a person treated by a health care 67
provider in the state under a policy, plan, or con tract. 68
(2) Beginning January 1, 2024, a utilization review entity 69
must establish a secure, interactive online electronic prior 70
authorization process for accepting electronic prior 71
authorization requests. The process must allow a person seeking 72
prior authorization to upload documentation if such 73
documentation is required by the utilization review entity to 74
adjudicate the prior authorization request. 75
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(3)(2) Notwithstanding any other provision of law, 76
effective January 1, 2017, or 6 six (6) months after the 77
effective date of the rule adopting the prior authorization 78
form, whichever is later, a utilization review entity that a 79
health insurer, or a pharmacy benefits manager on behalf of the 80
health insurer, which does not provide an electronic prior 81
authorization process for use by its contracted providers , shall 82
only use only the prior authorization form that has been 83
approved by the Financial Services Commission for granting a 84
prior authorization for a medical procedure, course of 85
treatment, or prescription d rug benefit. Such form may not 86
exceed two pages in length, excluding any instructions or 87
guiding documentation, and must include all clinical 88
documentation necessary for the utilization review entity health 89
insurer to make a decision. At a minimum, the for m must include: 90
(1) sufficient patient information to identify the member, date 91
of birth, full name, and Health Plan ID number; (2) provider 92
name, address and phone number; (3) the medical procedure, 93
course of treatment, or prescription drug benefit being 94
requested, including the medical reason therefor, and all 95
services tried and failed; (4) any laboratory documentation 96
required; and (5) an attestation that all information provided 97
is true and accurate. 98
(4)(3) The Financial Services Commission in consultation 99
with the Agency for Health Care Administration shall adopt by 100
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rule guidelines for all prior authorization forms which ensure 101
the general uniformity of such forms. 102
(5)(4) Electronic prior authorization a pprovals do not 103
preclude benefit verification or medical review by the insurer 104
under either the medical or pharmacy benefits. 105
(6) A utilization review entity's prior authorization 106
process may not require information that is not needed to make a 107
determination or facilitate a determination of medical necessity 108
of the requested medical procedure, course of treatment, or 109
prescription drug benefit. 110
(7) A utilization review entity shall disclose all of its 111
prior authorization requirements and restrictions, in cluding any 112
written clinical criteria, on its website in a manner that is 113
readily accessible to the public. This information shall be 114
explained in detail and in clear and unambiguous language. 115
(8) A utilization review entity may not implement any new 116
requirements or restrictions or make changes to existing 117
requirements or restrictions on obtaining prior authorization 118
unless: 119
(a) The changes have been available on a publicly 120
accessible website for at least 60 days before being 121
implemented. 122
(b) Insureds and health care providers who are affected by 123
the new requirements and restrictions or changes to the 124
requirements and restrictions are provided with a written notice 125
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of the changes at least 60 days before being implemented. Such 126
notice must be delivered electronically or by other means as 127
agreed to by the insured or the health care provider. 128
(9) A utilization review entity shall make statistics 129
available regarding prior authorization approvals and denials on 130
its website in a manner that is readily acces sible to the 131
public. The statistics must include categories for: 132
(a) Physician specialty. 133
(b) Medication or diagnostic test or procedure. 134
(c) Indication offered. 135
(d) Reason for denial. 136
(e) Appeal. 137
(f) Approval or denial on appeal. 138
(g) The time between submission and the response. 139
140
This subsection does not apply to the expansion of health care 141
services coverage. 142
(10) A utilization review entity must ensure that all 143
adverse determinations are made by a physician licensed under 144
chapter 458 or chapter 459 who: 145
(a) Possesses a current, valid, and unrestricted license 146
to practice medicine in the state. 147
(b) Is of the same specialty as the physician who 148
typically manages the medical condition or disease or provides 149
the health care service involv ed in the request. 150
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(c) Has experience treating patients with the medical 151
condition or disease for which the health care service is being 152
requested. 153
(11) Notice of an adverse determination shall be provided 154
by electronic mail to the insured and the heal th care provider 155
that initiated the prior authorization. Notice required under 156
this subsection must include: 157
(a) The name, title, e -mail address, and telephone number 158
of the physician responsible for making the adverse 159
determination. 160
(b) The written clinical criteria, if any, and any 161
internal rule, guideline, or protocol on which the utilization 162
review entity relied when making the adverse determination and 163
how those provisions apply to the insured's specific medical 164
circumstance. 165
(c) Information for the insured and the insured's health 166
care provider which describes the procedure through which the 167
insured or health care provider may request a copy of any report 168
developed by personnel performing the review that led to the 169
adverse determination. 170
(d) Information that explains to the insured and the 171
insured's healthcare provider how to appeal the adverse 172
determination. 173
(12) If a utilization review entity requires prior 174
authorization of a nonurgent health care service, the 175
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utilization review entity shall make an authorization or adverse 176
determination and notify the insured and the insured's health 177
care provider of the decision within 2 business days after 178
obtaining all necessary information to make the authorization or 179
adverse determination. As used in th is subsection, the term 180
"necessary information" includes the results of any face -to-face 181
clinical evaluation or second opinion that may be required. 182
(13) A utilization review entity shall render an expedited 183
authorization or adverse determination concern ing an urgent 184
health care service and notify the insured and the insured's 185
health care provider of that expedited prior authorization or 186
adverse determination no later than 1 business day after 187
receiving all information needed to complete the review of the 188
requested urgent healthcare service. 189
(14) A utilization review entity may not require prior 190
authorization for prehospital transportation or for provision of 191
an emergency health care service. 192
(15) A utilization review entity may not require prior 193
authorization for the provision of medications for opioid use 194
disorder. As used in this subsection, the term "medications for 195
opioid use disorder" means the use of United States Food and 196
Drug Administration approved medications, commonly in 197
combination with counseling and behavioral therapies, to provide 198
a comprehensive approach to the treatment of opioid use 199
disorder. Food and Drug Administration approved medications used 200
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to treat opioid addiction inc lude, but are not limited to, 201
methadone, buprenorphine, alone or in combination with naloxone, 202
and extended-release injectable naltrexone. Types of behavioral 203
therapies include, but are not limited to, individual therapy, 204
group counseling, family behavior therapy, motivational 205
incentives, and other modalities. 206
(16) A utilization review entity may not revoke, limit, 207
condition, or restrict a prior authorization if care is provided 208
within 45 business days after the date the health care provider 209
received the prior authorization. A utilization review entity 210
must pay the health care provider at the contracted payment rate 211
for a health care service provided by the health care provider 212
per prior authorization unless: 213
(a) The health care provider knowingly and ma terially 214
misrepresented the health care service in the prior 215
authorization request with the specific intent to deceive and 216
obtain an unlawful payment from the utilization review entity; 217
(b) The health care service was no longer a covered 218
benefit on the day it was provided, and the utilization review 219
entity notified the health care provider in writing of this fact 220
before the health care service was provided; 221
(c) The health care provider was no longer contracted with 222
the insured's health insurance plan on the date the care was 223
provided, and the utilization review entity notified the health 224
care provider in writing of this fact before the health care 225
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service was provided; 226
(d) The health care provider failed to meet the 227
utilization review entity's timely f iling requirements; 228
(e) The authorized service was never performed; or 229
(f) The patient was no longer eligible for health care 230
coverage on the day the care was provided, and the utilization 231
review entity notified the health care provider in writing of 232
this fact before the health care service was provided. 233
(17) If a utilization review entity required a prior 234
authorization for a health care service for the treatment of a 235
chronic or long-term care condition, the prior authorization 236
remains valid for the l ength of the treatment and the 237
utilization review entity may not require the insured to obtain 238
a prior authorization again for the health care service. 239
(18) A utilization review entity may not impose an 240
additional prior authorization requirement with re spect to a 241
surgical or otherwise invasive procedure, or any item provided 242
as part of the surgical or invasive procedure, if the procedure 243
or item is provided during the perioperative period of another 244
procedure for which prior authorization was granted by the 245
health insurer. 246
(19) If there is a change in coverage or approval criteria 247
for a previously authorized health care service, the change in 248
coverage or approval criteria may not affect an insured who 249
received prior authorization before the effective da te of the 250
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change for the remainder of the insured's policy, plan, or 251
contract year. 252
(20) A utilization review entity shall continue to honor a 253
prior authorization that it has granted to an insurer when the 254
insurer changes products under the same health i nsurer. 255
(21) A failure by a utilization review entity to comply 256
with the deadlines and other requirements of this section will 257
result in a health care service subject to review to be 258
automatically deemed authorized by the utilization review 259
entity. 260
(22) The provisions of this section may not be waived by 261
any policy, plan, or contract. Any policy, plan, or contractual 262
arrangements or any actions taken in conflict with this section 263
or that purport to waive any requirements of this section are 264
void. 265
Section 2. This act shall take effect July 1, 2023. 266