SLS 20RS-346 ORIGINAL
2020 Regular Session
SENATE BILL NO. 292
BY SENATOR JACKSON
INSURANCE POLICIES. Provides relative to utilization reviews for health insurance
policies. (8/1/20)
1 AN ACT
2 To amend and reenact R.S. 22:1016(A) and to enact Subpart P of Part III of Chapter 4 of
3 Title 22 of the Louisiana Revised Statutes of 1950, to be comprised of R.S.
4 22:1260.41 through 1260.48, relative to health insurance; to provide for utilization
5 reviews; to provide for definitions; to provide for documentation; to provide for
6 decisions and notifications; to provide for reporting; and to provide for related
7 matters.
8 Be it enacted by the Legislature of Louisiana:
9 Section 1. R.S. 22:1016(A) is hereby amended and reenacted and Subpart P of Part
10 III of Chapter 4 of Title 22 of the Louisiana Revised Statutes of 1950, comprised of R.S.
11 22:1260.41 through 1260.48 is hereby enacted to read as follows:
12 §1016. Regulation by the Department of Insurance and the Louisiana Department of
13 Health of prepaid entities participating in the Louisiana Medicaid
14 Program
15 A. Notwithstanding any law to the contrary, any prepaid entity that
16 participates in the Louisiana Medicaid Program shall obtain an insurer license or
17 certificate of authority from the Louisiana Department of Insurance. Any prepaid
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1 entity participating in the Louisiana Medicaid Program shall be regulated by the
2 Louisiana Department of Insurance with respect to licensure and financial solvency
3 but shall, solely with respect to its products and services offered pursuant to the
4 Louisiana Medicaid Program, be regulated by the Louisiana Department of Health,
5 subject to 42 USCA §1396 et seq., and all applicable federal and state laws, rules,
6 and regulations relating to the Louisiana Medicaid Program. The Louisiana
7 Department of Health shall have the authority to adopt and promulgate rules and
8 regulations, including certification requirements, relating to the Louisiana Medicaid
9 Program. Except for licensure, and financial solvency requirements, and the
10 provisions of Subpart P of Part III of Chapter 4 of this Title, no other provisions
11 of this Title shall apply to a prepaid entity with respect to the participation of the
12 prepaid entity in the Louisiana Medicaid Program.
13 * * *
14 SUBPART P. UTILIZATION REVIEW STANDARDS
15 §1260.41. Definitions
16 For purposes of this Part, the following terms have the following
17 meanings unless the context clearly indicates otherwise:
18 (1) "Adverse determination" is a determination by a health insurance
19 issuer or utilization review entity that an admission, availability of care,
20 continued stay, or other healthcare service furnished or proposed to be
21 furnished to an enrollee has been evaluated and, based upon the information
22 provided, does not meet a health insurance issuer's requirements for medical
23 necessity, appropriateness, healthcare setting, level of care, or effectiveness, or
24 is experimental or investigational, and the requested service is therefore denied,
25 reduced, or terminated.
26 (2) "Ambulatory review" means a utilization review of healthcare
27 services performed or provided in an outpatient setting.
28 (3) "Certification" means a determination by a health insurance issuer
29 or a utilization review entity that an admission, availability of care, continued
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1 stay, or other healthcare service has been reviewed and, based on the
2 information provided, satisfies the health insurance issuer's requirements for
3 medical necessity, appropriateness, healthcare setting, level of care, and
4 effectiveness, and that payment will be made for that healthcare service,
5 provided the patient is an enrollee of the health benefit plan at the time the
6 service is provided.
7 (4) "Clinical review criteria" means the written policies, written
8 screening procedures, drug formularies or lists of covered drugs, determination
9 rules, decision abstracts, clinical protocols, medical protocols, practice
10 guidelines, and any other criteria or rationales used by the health insurance
11 issuer or utilization review entity to determine the necessity and
12 appropriateness of healthcare services.
13 (5) "Commissioner" means the commissioner of the Louisiana
14 Department of Insurance.
15 (6) "Concurrent review" means utilization review conducted during a
16 patient's hospital stay or course of treatment.
17 (7) "Department" means the Louisiana Department of Insurance.
18 (8) "Health insurance issuer" means an entity subject to the insurance
19 laws and regulations of this state or subject to the jurisdiction of the
20 commissioner that contracts or offers to contract or enters into an agreement
21 to provide, deliver, arrange for, pay for, or reimburse any of the costs of
22 healthcare services, including a sickness and accident insurance company, a
23 health maintenance organization, a preferred provider organization or any
24 similar entity, any other entity providing a plan of health insurance or health
25 benefits, or a "managed care organization" as defined by 42 CFR 438.2.
26 (9) "Prior authorization" means a certification made pursuant to a prior
27 authorization review or notice as required by a health insurance issuer prior to
28 the provision of any healthcare service.
29 (10) "Prior authorization review" means a utilization review of medical
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1 necessity conducted prior to an admission or a course of treatment, including
2 but not limited to pre-admission review, pre-treatment review, and case
3 management.
4 (11) "Retrospective review" means a utilization review of medical
5 necessity conducted after services have been provided to a patient but does not
6 include the review of a claim that is limited to an evaluation of reimbursement
7 levels, veracity of documentation, accuracy of coding or adjudication for
8 payment.
9 (12) "Utilization review" means the application of a set of formal
10 techniques designed to monitor the use of, or evaluate the clinical necessity,
11 appropriateness, efficacy, or efficiency of healthcare services, procedures, or
12 settings. Techniques include but are not limited to ambulatory review, prior
13 authorization review, second opinion, certification, concurrent review, case
14 management, discharge planning, or retrospective review. "Utilization review"
15 shall not include elective clarification of coverage.
16 (13) "Utilization review entity" means an individual or entity that
17 performs prior authorization examinations for a health insurance issuer. A
18 health insurance issuer or healthcare provider is a utilization review entity if it
19 directly performs prior authorization reviews.
20 §1260.42. Documented prior authorization program; general requirement
21 A. A health insurance issuer that requires the satisfaction of a utilization
22 review as a condition of payment of a claim submitted by a healthcare provider
23 shall maintain a documented prior authorization program that implements
24 evidenced-based clinical review criteria. The prior authorization program shall
25 include a method for reviewing and updating clinical review criteria.
26 B. If a health insurance issuer engages a third-party utilization review
27 entity to perform utilization reviews, the health insurance issuer shall be
28 responsible for ensuring that the requirements of this Subpart and applicable
29 rules and regulations are met by the third-party utilization review entity.
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1 C. In addition to fulfilling the requirements of this Subpart, a prior
2 authorization program shall meet standards set forth by a national
3 accreditation organization including but not limited to the National Committee
4 for Quality Assurance (NCQA), the Utilization Review Accreditation
5 Commission (URAC), and the Accreditation Association for Ambulatory Health
6 Care. A health insurance issuer or utilization review entity shall ensure that the
7 utilization review program employs staff who are properly qualified, trained,
8 supervised, and supported by explicit written current clinical review criteria
9 and review procedures.
10 D. A health insurance issuer that requires utilization review for any
11 service shall allow healthcare providers to submit requests for utilization review
12 at any time, including outside normal business hours. Within twenty-four hours
13 of receiving an oral or written request from a healthcare provider, the health
14 insurance issuer shall provide the specific clinical review criteria used by the
15 health insurance issuer to make a utilization review determination.
16 E.(1) A health insurance issuer shall maintain a system of recording
17 information and supporting clinical documentation submitted by healthcare
18 providers seeking utilization review. This information shall be maintained by
19 the health insurance issuer until the claim has been paid or the claim appeals
20 process has been exhausted unless the information is otherwise required to be
21 retained for a longer period of time by state or federal law or regulation.
22 (2) A health insurance issuer shall provide a unique case number to a
23 healthcare provider upon receipt from that provider of a request for utilization
24 review. Except as otherwise requested by the healthcare provider in writing, the
25 unique case number shall be transmitted or otherwise communicated through
26 the same medium through which the request for utilization review was made.
27 (3) Upon request of the provider or facility, a health insurance issuer or
28 a utilization review entity shall send to the provider or facility written
29 acknowledgment of receipt of each document submitted by the provider or
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1 facility during the processing of a prior authorization request.
2 (4) When the provider or facility transmits information by telephone, a
3 health insurance issuer shall provide written acknowledgment of the
4 information communicated by the provider or facility.
5 §1260.43. Single utilization review per episode of care
6 A health insurance issuer shall not impose any additional utilization
7 review requirement with respect to any surgical or otherwise invasive
8 procedure or any item furnished as part of that surgical or invasive procedure,
9 if the procedure item is furnished during the perioperative period of a
10 procedure when either of the following conditions is met:
11 (1) Prior authorization was received from the health insurance issuer
12 before the procedure or item was furnished.
13 (2) Prior authorization was not required by the health insurance issuer.
14 §1260.44. Suspension of utilization review
15 In the event a hospital or healthcare provider has performed a procedure
16 an average of thirty times per year over a period of two years and in a
17 six-month time period has received certifications for ninety percent of the
18 utilization reviews for that procedure, the health insurance issuer shall not
19 require the hospital or healthcare provider to request utilization review for that
20 procedure for the following six months. At the end of the six-month term, the
21 suspension shall be reviewed prior to renewal. This suspension is subject to
22 internal auditing at any time by the health insurance issuer and may be
23 rescinded if the health insurance issuer determines the hospital or healthcare
24 practitioner is not performing the procedure in conformity with the health
25 insurance issuer's benefit plan.
26 §1260.45. Timeframes for decision
27 A. A health insurance issuer shall maintain written procedures for
28 making utilization review decisions and for notifying enrollees and providers
29 acting on behalf of enrollees of its decisions. For purposes of this Section,
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1 "enrollee" includes the representative of an enrollee. A health insurance issuer
2 or utilization review entity shall make a utilization review decision as
3 expeditiously as the member's health condition requires, but in all cases no later
4 than the time periods required in this Section.
5 B.(1) For utilization review determinations that are neither concurrent
6 or retrospective review determinations, a health insurance issuer or utilization
7 review entity shall make the determination within thirty-six hours of the initial
8 request, which shall include one business day, of obtaining all necessary
9 information regarding a proposed admission, procedure, or service requiring
10 a review determination.
11 (2) The health insurance issuer shall give an initial notification of the
12 decision to the requesting provider rendering the service by telephone or
13 electronically within twenty-four hours of making the decision and provide
14 written or electronic confirmation of the initial notification to the insured and
15 the provider within three business days of making the decision.
16 (3) If a healthcare provider or facility believes that the time
17 specifications provided in Paragraphs (1) and (2) of this Subsection are so long
18 that they could seriously jeopardize the life or health of an insured or the
19 insured's ability to attain, maintain, or regain maximum function, or that a
20 delay in treatment would subject the insured to severe pain that could not be
21 adequately managed without the service requested, the healthcare provider
22 shall request an expedited review and the health insurance issuer shall make the
23 determination within twenty-four hours of obtaining all necessary information
24 from the provider or facility. The health insurance issuer shall give, either by
25 telephone or electronically, an initial notification of the decision to the provider
26 within twenty-four hours of the health insurance issuer making the decision and
27 shall provide written confirmation of the decision within three business days of
28 making the determination.
29 C.(1) For concurrent review determinations, a health insurance issuer
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1 or utilization review entity shall make the determination within twenty-four
2 hours of obtaining all necessary information from the provider or facility.
3 (2) In the case of a determination to certify an extended stay or
4 additional services, the health insurance issuer shall give an initial notification
5 of the decision to the provider rendering the service either by telephone or
6 electronically within twenty-four hours of making the decision, and provide
7 written confirmation to the enrollee and the provider within three working days
8 after the certification. The initial and written notifications shall include the
9 number of extended days or next review date, the new total number of days or
10 services approved, and the date of admission or initiation of services.
11 (3) In the case of an adverse determination, the health insurance issuer
12 shall make an initial notification to the provider by telephone or electronically
13 within twenty-four hours of making the adverse determination and provide
14 written or electronic notification to the enrollee and the provider within three
15 working days of making the adverse determination.
16 D. For retrospective review determinations, a health insurance issuer
17 shall make the determination within thirty working days of receiving all
18 necessary information. A health insurance issuer shall provide notice in writing
19 of the issuer's determination to an enrollee within ten working days of making
20 the determination.
21 E. For purposes of this Section, "necessary information" includes the
22 results of any face-to-face clinical evaluation or second opinion that may be
23 required. If the request for utilization review from the participating provider
24 or facility is not accompanied by all necessary information required by the
25 health insurance issuer, the health insurance issuer shall have one calendar day
26 to inform the provider or facility what additional information is necessary to
27 make the determination and shall allow a provider or facility no less than two
28 business days to provide the necessary information to the health insurance
29 issuer. In cases where the provider or an enrollee will not release necessary
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1 information, the health insurance issuer may deny certification of an admission,
2 procedure, or service.
3 F. A written notification of an adverse determination shall include the
4 principal reason or reasons for the determination including the clinical
5 rationale and the instructions for initiating an appeal or reconsideration of the
6 determination. A health insurance issuer shall provide the clinical rationale for
7 an adverse determination in writing, including the clinical review criteria used
8 to make that determination, to the healthcare provider and to any party who
9 received notice of the adverse determination.
10 G. If a health insurance issuer fails to make a determination within the
11 timeframes required in this Section, the health insurance issuer shall be
12 prohibited from denying the claim based upon a lack of prior authorization.
13 §1260.46. Documentation
14 A health insurance issuer, when conducting a utilization review
15 determination, shall:
16 (1) Accept any evidence-based information from a provider or facility
17 that will assist in the authorization process.
18 (2) Collect only the information necessary to authorize the service and
19 maintain a process for the provider or facility to submit any records.
20 (3) If medical records are requested, require only the portion of the
21 medical record necessary in that specific case to determine medical necessity or
22 appropriateness of the service to be delivered, to include admission or extension
23 of stay, and frequency or duration of service.
24 (4) Base review determinations on the medical information in the
25 enrollee's records and obtained by the health insurance issuer up to the time of
26 the review determination.
27 §1260.47. Utilization review decisions
28 A. When a healthcare provider or facility makes a request for the
29 utilization review, the response from the health insurance issuer shall state if it
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1 is certified or denied. If the request is denied, the response shall give the specific
2 reason for the denial in clear and simple language. If the reason for the denial
3 is based on clinical review criteria, the specific criteria shall be provided. A
4 denial of a utilization review request shall include the department and
5 credentials of the individual who has the authority to approve or deny the
6 request. A denial shall also include a phone number to contact the authorizing
7 entity and a notice regarding the enrollee's appeal rights and process. If a
8 request for utilization review is denied by the health insurance issuer and the
9 healthcare provider requests an appeal by peer review of the decision to deny,
10 the peer review shall be with a healthcare practitioner similar in specialty,
11 education, and background. The health insurance insurer's medical director has
12 the ultimate authority regarding the appeal determination, and the healthcare
13 provider has the option to consult with the medical director after the
14 peer-to-peer consultation. Timeframes for completion of this appeal process
15 shall take no longer than thirty days.
16 B. Provided the patient is an enrollee of the health benefit plan, a health
17 insurance issuer shall be prohibited from revoking, limiting, conditioning, or
18 otherwise restricting a utilization review certification within forty-five working
19 days of the date the healthcare provider receives the utilization review
20 certification.
21 §1260.48. Utilization review reporting
22 A.(1) A health insurance issuer shall on an annual basis and at a time
23 and in a manner specified by the commissioner submit to the department the
24 following information:
25 (a) A list of all items and services subject to a utilization review
26 requirement under each health benefit plan offered by the health insurance
27 issuer.
28 (b) The percentage of utilization review requests approved during the
29 previous plan year by the health insurance issuer with respect to each item and
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1 service.
2 (c) The percentage of requests for utilization review for the previous plan
3 year that were initially denied and that were subsequently appealed, and the
4 percentage of appealed requests that were overturned, with respect to each item
5 and service.
6 (d) The average and the median amount of time, in hours, that elapsed
7 during the previous plan year between the submission of a request for a
8 utilization review to the health insurance issuer and a determination by the plan
9 with respect to that request for each item and service, excluding any requests
10 that did not contain all information required to be submitted by the health
11 insurance issuer.
12 (e) Such other information as the commissioner determines appropriate
13 after consultation with and comment from stakeholders.
14 (2) The commissioner shall submit an annual report to the House and
15 Senate committees on insurance containing the information submitted to the
16 department pursuant to Subsection A of this Section.
17 B. A health insurance issuer annually and before open enrollment shall
18 publish a list of all items and services that are subject to a prior authorization
19 requirement under each health benefit plan on a publicly available website,
20 shall provide the address of the website in any enrollment materials distributed
21 by the plan, and shall update the website in a timely manner.
22 C. A health insurance issuer shall provide, along with contract materials
23 for any provider or supplier who seeks to participate under a health benefit
24 plan, a list of all items and services that are subject to a prior authorization
25 requirement under the plan and any policies or procedures used by the plan for
26 making determinations with respect to prior authorization requests.
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The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Cheryl B. Cooper.
DIGEST
SB 292 Original 2020 Regular Session Jackson
Proposed law provides definitions including "utilization review" which is the application of
a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity,
appropriateness, efficacy, or efficiency of healthcare services, procedures, or settings.
Provides for techniques that include but are not limited to ambulatory review, prior
authorization review, second opinion, certification, concurrent review, case management,
discharge planning, or retrospective review.
Proposed law requires a health insurer that demands a review as a condition of payment of
a claim submitted by a healthcare provider to maintain a documented prior authorization
program that utilizes evidenced-based clinical review criteria.
Proposed law requires a prior authorization program to meet standards set forth by a national
accreditation organization including but not limited to the National Committee for Quality
Assurance, the Utilization Review Accreditation Commission, and the Accreditation
Association for Ambulatory Health Care.
Proposed law allows a healthcare provider to submit a request for utilization review for any
service at all times including outside normal business hours. Provides that within 24 hours
of receiving either an oral or written request from a healthcare provider, the health insurance
issurer shall provide the specific clinical review criteria used by the health insurance issuer
to make a utilization review determination.
Proposed law requires a health insurance issuer to maintain a system of recording
information and supporting clinical documentation submitted by healthcare providers
seeking a utilization review. Requires a health insurance issuer to provide a unique case
number to a healthcare provider upon receipt from that provider of a request for utilization
review.
Proposed law prohibits a health insurance issuer from imposing any additional utilization
review requirements with respect to any surgical or otherwise invasive procedure and any
item furnished as part of a surgical or invasive procedure under certain conditions.
Proposed law provides in the event a hospital or healthcare provider has performed a
procedure an average of 30 times per year for two years and in a six-month time period has
received certifications for 90% of the utilization reviews, the health insurance issuer shall
not require the hospital or healthcare provider to request utilization review for the procedure
for the following six months.
Proposed law provides for utilization review determinations that are neither concurrent nor
retrospective review determinations, a health insurance issuer or utilization review entity
shall make the determination within 36 hours, which shall include one business day, of
obtaining all necessary information regarding a proposed admission, procedure, or service
requiring a utilization review determination. Requires the health insurance issuer to make
an initial notification to the requesting provider rendering the service of the decision by
telephone or electronically within 24 hours of making the decision and to provide written
or electronic confirmation of the initial notification to the insured and the provider within
three business days of making the certification.
Proposed law requires in the case of concurrent review determinations, a health insurance
issuer or utilization review entity shall make the determination within 24 hours of obtaining
all necessary information from the provider or facility.
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Proposed law requires a written notification of an adverse determination to include the
principal reason or reasons for the determination, including the clinical rationale, and the
instructions for initiating an appeal or reconsideration of the determination.
Proposed law provides for the required documentation a health insurance issuer must provide
when conducting a utilization review determination.
Proposed law details the requirements for the response from the health insurance issuer in
the event of a request for the utilization review by a healthcare provider or facility.
Proposed law requires a health insurance issuer, on an annual basis, and at a time and in a
manner determined by the commissioner, to submit to the department specific information
regarding utilization reviews. Requires the commissioner to submit to the House and Senate
committees on insurance an annual report of the information submitted by a health insurance
issuer.
Effective August 1, 2020.
(Amends R.S. 22:1016(A); adds R.S. 22:1260.41-22:1260.48)
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