SSHB468 3264 4051
HOUSE SUMMARY OF SENATE AMENDMENTS
HB 468 2023 Regular Session Pressly
INSURANCE/HEALTH: Provides relative to utilization review standards and approval
procedures for healthcare service claims submitted by healthcare providers
Synopsis of Senate Amendments
1.Defines "urgent condition".
2.Changes "48-hours" to "2 business days" with respect to a health insurance
issuer's required response time to a provider's request for prior authorization.
3.Changes "2 days" to "2 business days" with respect to a health insurance issuer's
required response time to a physician of the issuer's peer review determination.
4.Reduces the timeframe for which a prior authorization remains valid from a
minimum of 6 months from certification to a minimum of 3 months from
certification.
5. Adds that proposed law does not preclude a health insurance issuer from
conducting investigations of possible fraud, waste, or abuse or from taking
appropriate actions based upon the results of such investigations.
6.Makes technical changes.
Digest of Bill as Finally Passed by Senate
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 additional utilization review requirements
with respect to any surgical or invasive procedure or any item furnished thereof.
Determinations based on exigency. Proposed law requires an issuer or entity to offer an
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expedited review for prior authorization of a provider's request that is medically necessary
for the treatment or management of a patient's urgent condition. Requires the issuer to
electronically communicate its decision to the provider as soon as possible, but not more than
2 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
notification to the enrollee and the provider within 2 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 all reasons for denial, including any clinical review criteria.
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 for the enrollee's use for an appeal.
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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 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 3 months from the date of certification.
Proposed law does not preclude a health insurance issuer from conducting investigations of
possible fraud, waste, or abuse or from taking appropriate actions based upon the results of
such investigations.
Effective on Jan. 1, 2024.
(Adds R.S. 22:1260.41-1260.48)
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