DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part of the
legislative instrument. The keyword, one-liner, abstract, and digest do not constitute part of the law
or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 468 Reengrossed 2023 Regular Session Pressly
Abstract: Requires standards for prior authorization and approval procedures, including
timeframes, for health insurance issuers to determine healthcare service claims submitted by
healthcare providers.
Proposed law defines "adverse determination", "ambulatory review", "certification", "clinical review
criteria", "concurrent review", "healthcare facility", "healthcare professional", "healthcare provider",
"healthcare services", "health insurance issuer", "prior authorization", "retrospective review",
"utilization review", and "utilization review entity".
Proposed law requires a health insurance issuer (issuer) that mandates a satisfactory utilization
review as a condition of payment for the claim of a healthcare provider (provider) to maintain a
documented prior authorization program that utilizes evidenced-based clinical review criteria.
Authorizes an issuer to employ a third-party utilization review entity (entity) to perform utilization
review and requires a prior authorization program to meet standards set forth by a national
accreditation organization. Further authorizes an issuer to refer the provider to the specific criteria
by electronic means.
Proposed law authorizes a provider to submit a request for utilization review for any service to an
issuer at any time, including outside normal business hours. Requires an issuer to notify the provider
of the specific clinical review criteria to be used for the specific item or service in its utilization
review determination within 72 hours of receiving either an oral or written request from a provider.
Proposed law requires an issuer to maintain a system of recording supporting clinical documentation
submitted by providers seeking utilization review. Requires an issuer to assign a unique case number
upon receipt of the provider's request for utilization review.
Proposed law prohibits an issuer from imposing any additional utilization review requirements with
respect to any surgical or invasive procedure or any item furnished as part of a surgical or invasive
procedure under certain conditions.
Determinations based on exigency. Proposed law requires an issuer or entity to offer an expedited
review by electronic means to the provider requesting prior authorization. Requires the issuer to
electronically communicate its decision to the provider as soon as possible, but not more than 48
hours from receipt of the request. Further provides that if additional information is needed, the
issuer or entity is required to electronically communicate its decision to the provider as soon as
possible, but not more than 48 hours from receipt of the required additional information. Proposed law provides that for any requests from a provider for prior authorization for which the
issuer does not receive a request for expedited review, the issuer is required to communicate its
decision on the prior authorization request no more than 5 business days from the receipt of the
request. Further provides that if the issuer needs and requests additional information to make its
determination, the issuer is required to communicate its decision to the provider no more than 5
business days from receipt of the additional information.
Determinations for concurrent review. Proposed law requires an issuer to make a determination
within 24 hours of obtaining all necessary information from the provider or facility. If the
determination is to extend a patient's stay or certify additional services, proposed law requires the
issuer or entity to provide an initial notification of its certification to the provider by telephone or
electronically within 24 hours of making the certification. Further requires the issuer to provide
written or electronic confirmation of the initial notification to the enrollee and the provider within
3 business days of making the certification.
Determinations for retrospective review. Proposed law requires an issuer to make the determination
within 30 business days of receiving all necessary information. Requires the issuer to provide notice
of the determination in writing to the enrollee and provider within 3 business days of making the
retrospective review determination.
For adverse determinations, proposed law requires an issuer to provide an initial notification to the
provider by telephone or electronically within 24 hours of making the adverse determination.
Requires the issuer to provide written or electronic notification to the enrollee and the provider
within 3 business days of making the adverse determination.
Proposed law describes the necessary information required by a provider or enrollee for submission
to an issuer. Prescribes that if a provider's request for utilization review does not provide all
necessary information, the issuer has 1 calendar day to inform the provider of the particular
additional necessary information needed for determination, and the provider has at least 2 business
days to provide the necessary information to the issuer.
Proposed law authorizes an issuer to deny certification of an admission, procedure, or service if the
provider or enrollee will not release necessary information, but if the issuer fails to make a
determination within the timeframes prescribed in proposed law, the issuer is prohibited from
denying a claim based on a lack of prior authorization.
Proposed law requires an issuer to accept any evidence-based information and to collect only the
information necessary for authorization from a provider that will assist in the utilization review, and
to base its review determinations on the medical information in the enrollee's records obtained by
the issuer up to the time of the review determination.
Proposed law requires an issuer to state if its response to a provider's request for utilization review
is to certify or deny the request. If the request is denied, proposed law requires the issuer to give in
the response the specific reason for the denial in clear and simple language, including any clinical
review criteria that was the basis for denial.
Proposed law requires an issuer's denial of a utilization review request to include the department and
credentials of the individual authorized to approve or deny the request, including the phone number
of the authorizing authority regarding the enrollee's right to appeal.
Proposed law provides that if a provider requests a peer review of the determination to deny, the
issuer is required to appoint a licensed healthcare practitioner similar in education and background
or a same-or-similar specialist to conduct the peer review with the requesting provider. Requires the
reviewing same-or-similar specialist's training and experience to meet certain criteria with respect
to the providing of treatment.
Proposed law requires an issuer to appoint a physician to conduct the review and to notify the
requesting physician of its peer review determination within 2 days of the date of the peer review.
Proposed law prohibits an issuer from denying any claim subsequently submitted by a healthcare
provider for healthcare services specifically included in a prior authorization unless certain
circumstances apply. Further requires an issuer's certification of prior authorization to remain valid
for a minimum of 6 months.
Effective on Jan, 1, 2024.
(Adds R.S. 22:1260.41-1260.47)
Summary of Amendments Adopted by House
The Committee Amendments Proposed by House Committee on Insurance to the original bill:
1. Make technical changes.
The House Floor Amendments to the engrossed bill:
1. Provide that a "health insurance issuer" means the administration of any self-insured or
self-funded health plan.
2. Provide that a "healthcare provider" means an ambulance service as defined in present
law.
3. Change the timeframe for which a health insurance issuer is required to notify the
provider of the specific clinical review criteria to be used for its utilization review
determination from within 24 hours to within 72 hours of receiving either an oral or
written request from a provider. Authorize an issuer to electronically refer the provider
to the specific criteria. 4. Require a health insurance issuer or utilization review entity to offer an expedited review
by electronic means and to communicate its decision to the provider as soon as possible,
but not more than 48 hours from receipt of the request.
5. Require a health insurance issuer to communicate to the provider its decision on non-
expedited prior authorization requests within 5 business days from the receipt of the
request.
6. Remove a health insurance issuer's right to recoup payment from enrollees.
7. Make changes with respect to peer review and qualifications of reviewing specialists.
8. Change the effective date from the date of the governor's signature to Jan. 1, 2024.
9. Make technical changes.