GREEN SHEET REDIGEST
HB 468 2023 Regular Session Pressly
INSURANCE/HEALTH. Louisiana Bureau of Criminal Identification and
Information.
DIGEST
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","urgent condition", "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. Provides that notice may be provided in electronic format.
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 for any request requiring
certification by a provider that is medically necessary for the treatment of an urgent condition
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 two business days 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 healthcare services requiring
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
five 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 five 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
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Prepared by Beth O'Quin. notification to the enrollee and the provider within two 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 one 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 two business 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 three months.
Effective on Jan. 1, 2024.
(Adds R.S. 22:1260.41-1260.47)
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Prepared by Beth O'Quin. 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.
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Insurance to the reengrossed
bill
1. Defines urgent condition.
2. Authorizes notifications can be sent by electronic format.
3. Requires requests that require certification by a provider is medically necessary
for the treatment of an urgent condition.
4. Requires a utilization review or a health insurer for an expedited review provide
the provider with a decision as soon as possible but not more than two business
days.
5. Adds healthcare services for when a provider requests a prior authorization that
is not for an expedited review.
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Prepared by Beth O'Quin. 6. Requires a health insurance issuer that makes an adverse determination to include
all of the reasons for making the adverse determination.
7. Requires the health insurance issuer has one calendar day to inform the provider
that additional information is needed to make a determination.
8. Requires the health insurance issuer notify the physician of its peer determination
within two business days.
9. Provides a health insurance issuer's certification of prior authorization is valid for
a minimum of three months.
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Prepared by Beth O'Quin.