Session of 2024
HOUSE BILL No. 2713
By Committee on Insurance
Requested by Representative Essex on behalf of the Kansas Hospital Association
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AN ACT concerning health and healthcare; relating to insurance; enacting
the ensuring transparency in prior authorization act; imposing certain
requirements and limitations on the use of prior authorization.
Be it enacted by the Legislature of the State of Kansas:
Section 1. (a) Sections 1 through 8, and amendments thereto, shall be
known and may be cited as the ensuring transparency in prior
authorization act.
(b) Sections 1 through 8, and amendments thereto, shall be a part of
and supplemental to article 32 of chapter 40 of the Kansas Statutes
Annotated, and amendments thereto.
(c) As used in sections 1 through 8, and amendments thereto:
(1) "Healthcare services" means services provided to an individual to
prevent, alleviate, cure or heal human illness or injury. "Healthcare
services" includes, but is not limited to: Medical, chiropractic, dental or
vision services; hospitalization; pharmaceutical services; or care or
services incidental to services described in this paragraph.
(2) "Physician" means an individual licensed by the state board of
healing arts to practice medicine and surgery.
(3) "Prior authorization" means a determination that: (A) Healthcare
services proposed to be provided to a patient are medically necessary and
appropriate; and (B) is made by an insurance company, health maintenance
organization or person contracting with an insurance company or health
maintenance organization.
(4) "Provider" means a:
(A) Person licensed by the state board of healing arts to practice any
branch of the healing arts;
(B) person who holds a temporary permit issued by the state board of
healing arts to practice any branch of the healing arts;
(C) medical care facility, as defined in K.S.A. 65-425, and
amendments thereto, that is licensed by the state of Kansas;
(D) podiatrist licensed by the state board of healing arts;
(E) health maintenance organization issued a certificate of authority
by the commissioner of insurance;
(F) optometrist licensed by the board of examiners in optometry;
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(G) pharmacist licensed by the state board of pharmacy;
(H) licensed professional nurse who is authorized by the board of
nursing to practice as a registered nurse anesthetist;
(I) licensed professional nurse who has been granted a temporary
authorization to practice nurse anesthesia under K.S.A. 65-1153, and
amendments thereto;
(J) physician assistant licensed by the state board of healing arts;
(K) licensed advanced practice registered nurse who is certified by
the board of nursing in the role of registered nurse anesthetist while
functioning as a registered nurse anesthetist;
(L) licensed advanced practice registered nurse who has been granted
an authorization by the board of nursing to practice in the role of certified
nurse-midwife;
(M) dentist licensed by the Kansas dental board under the dental
practices act; or
(N) person licensed, registered, certified or otherwise authorized by
the behavioral sciences regulatory board to practice a profession.
(5) "Utilization review entity" means an individual or entity that
performs prior authorization for:
(A) An employer with employees in Kansas who are covered under a
health benefit plan or health insurance policy;
(B) an insurer that writes health insurance policies;
(C) a preferred provider organization or health maintenance
organization; or
(D) any other individual or entity that provides, offers to provide or
administers hospital, outpatient, medical, prescription drug or other health
benefits to a person treated by a healthcare professional in Kansas under a
policy, plan or contract.
Sec. 2. (a) Not later than January 1, 2025, a utilization review entity
shall accept and respond to prior authorization requests under a pharmacy
benefit through a secure electronic transmission using the national council
for prescription drug programs script standard for electronic prior
authorization transactions. As used in this subsection, "secure electronic
transmission" does not include facsimile, proprietary payer portals,
electronic forms or any other technology that is not directly integrated with
a physician's electronic health record or electronic prescribing system.
(b) Not later than January 1, 2025, a utilization review entity shall
accept and respond to prior authorization requests for healthcare services
using a secure electronic portal at no cost to a healthcare provider. A
utilization review entity shall not require a healthcare provider to use a
specified secure electronic portal.
Sec. 3. (a) Not later than 24 hours after receiving all information
requested to complete a review of requested urgent healthcare services, a
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utilization review entity shall:
(1) Render a prior authorization or adverse determination and notify
the enrollee and enrollee's healthcare provider of such prior authorization
or adverse determination; and
(2) if the utilization review entity determines that additional
information is needed to render a prior authorization or adverse
determination, notify the healthcare provider that additional information is
needed.
(b) (1) A utilization review entity shall not require prior authorization
for pre-hospital transportation or the provision of emergency healthcare
services.
(2) A utilization review entity shall allow an enrollee and the
enrollee's healthcare provider not less than 24 hours following an
emergency admission or the provision of emergency healthcare services to
notify the utilization review entity of such admission or provision of
services. If an emergency admission or the provision of emergency
healthcare services occurs on a weekend or public holiday, a utilization
review entity shall not require notification until the next business day after
such admission or provision of services.
(3) Not later than two hours after receiving all information requested
to complete a review of requested emergency healthcare services, a
utilization review entity shall:
(A) Render a prior authorization or adverse determination and notify
the enrollee and enrollee's healthcare provider of such prior authorization
or adverse determination; and
(B) if the utilization review entity determines that additional
information is needed to render a prior authorization or adverse
determination, notify the healthcare provider that additional information is
needed.
(4) If a patient receives emergency healthcare services that require an
immediate post-evaluation or post-stabilization, a utilization review entity
shall render a prior authorization or adverse determination not later than
two hours after receiving the request for such post-evaluation or post-
stabilization.
(c) After receiving all information requested to complete a review of
regular healthcare services, a utilization review entity shall:
(1) Not later than 14 calendar days after such receipt, render a prior
authorization or adverse determination and notify the enrollee and
enrollee's healthcare provider of such prior authorization or adverse
determination; and
(2) if the utilization review entity determines that additional
information is needed to render a prior authorization or adverse
determination, not later than 48 hours after such receipt, notify the
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healthcare provider that additional information is needed.
(d) If a utilization review entity requires a prior authorization for a
healthcare service for the treatment of a chronic or long-term care
condition:
(1) Such prior authorization shall remain valid for the length of the
treatment; and
(2) the utilization review entity shall not require the enrollee to obtain
an additional prior authorization for such healthcare service.
Sec. 4. A utilization review entity shall not:
(a) Require prior authorization for birth by cesarean section or
vaginal delivery or neonatal intensive care services; or
(b) require notification of such services as a condition of payment for
such services.
Sec. 5. (a) A utilization review entity shall not retroactively deny
prior authorization for a covered healthcare service unless the prior
authorization was based on fraudulent information provided by an enrollee
or the enrollee's healthcare provider.
(b) A utilization review entity shall not revoke, limit, condition or
restrict a prior authorization if the healthcare service subject to the prior
authorization is:
(1) Initiated within 45 business days after the date the healthcare
provider received the prior authorization; and
(2) completed within the approved time period.
Sec. 6. (a) A healthcare provider may appeal any adverse
determination of a prior authorization request.
(b) Except as provided by subsection (c), a utilization review entity
shall complete adjudication of any requested appeal of an adverse
determination of a prior authorization request within 30 calendar days.
(c) If a healthcare provider indicates that a requested appeal is an
emergency, the utilization review entity shall provide for an expedited
phone appeal within 24 hours after the request. If the provider indicates
that the requested appeal is urgent, the utilization review entity shall
provide for such appeal within 72 hours after the request.
(d) A healthcare provider may prospectively request peer-to-peer
review in any appeal of an adverse determination of a prior authorization
request. If requested, such review shall be completed within 48 hours after
the request. For any appeal that includes a peer-to-peer review, the
utilization review committee shall provide a qualified peer who has
practiced in the same or similar specialty as the requesting healthcare
provider.
Sec. 7. (a) Each utilization review entity shall disclose all of the
utilization review entity's requirements and restrictions related to prior
authorization. Such requirements and restrictions shall be disclosed in a
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publicly accessible manner on the utilization review entity's website.
(b) A utilization review entity shall provide notice of any change to
the utilization review entity's prior authorization requirements or
restrictions to each healthcare provider subject to such requirements or
restrictions.
(c) On or before January 1, 2025, and annually thereafter, each
utilization review entity shall submit a report to the commissioner of
insurance providing statistics about the utilization review entity's prior
authorization practices. Such statistics shall include, but not be limited to,
the:
(1) Percentage of initial approvals and initial adverse determinations;
(2) percentage of initial adverse determinations categorized by
healthcare specialty;
(3) largest percentage of medication and diagnostic test adverse
determinations;
(4) reasons most frequently cited for adverse determinations;
(5) number of appeals requested; and
(6) percentage of appeals approved and denied.
(d) On or before January 1, 2025, and annually thereafter, the
insurance commissioner shall publish on the insurance commissioner's
website all reports submitted pursuant to subsection (c).
Sec. 8. If any provision or clause of this act or application thereof to
any person or circumstance is held invalid, such invalidity shall not affect
other provisions or applications of this act that can be given effect without
the invalid provision or application, and to this end the provisions of this
act are declared to be severable.
Sec. 9. This act shall take effect and be in force from and after its
publication in the Kansas register.
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